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

We decided that the Plan does not have to pay for special pump services
You asked the Plan to pay for the special pump services. You say that it takes a half hour to an hour to set up the Lung Machine. You say that the perfusionist is required to be in the operating room during the length of the procedure. You say that, per hospital protocol, it is mandatory that the surgeon, anesthesiologist, and perfusionist transport the patient to the unit and be there until the patient is in stable condition. The Plan denied your request. The Plan says the enrollee received the services in the facility during the inpatient hospitalization and payment for this service would be included in the Part-A DRG payment to the facility. The Plan says that the payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. Molly Wettach, CCP is a perfusionist and is not considered a physician. Therefore, the services supplied by this provider are considered non-physician services. Although these services may be appropriate, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Based on this information, we decided that Medicare rules for coverage of the special pump services have been met. Therefore, we decided that the Plan does not have to pay for special pump services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plandenied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee's medical conditions appear stable. There are no complex wound care needs and no unaddressed medical issues. She is currently in an outpatient setting and does not require an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She has a unilateral right lower extremity impairment without an identified significant upper extremity impairment. The enrollee does not require the intensity of an acute level rehabilitation therapy program. Additionally, an intensive rehabilitation therapy program wouldnotsignificantly impact the enrollee'scondition differently compared with therapy provided at a less intense level. The enrollee'scare can be appropriately provided at a skilled nursing level. 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-approvean 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 physician's services provided on October 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 physician's services provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electronic connection (E2311), expandable controller (E2377), harness (E2313), a positioning seat cushion (E2605) and a positioning back cushion (E2613) for the enrollee.You asked the Plan to pre-approvethese services. You say that these items are medically necessary.The Plan denied your request. The Plan says that these items 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 these items are not medically reasonable and necessary for the enrollee in this case. Records do not indicate an electronic connection, expandable controller and harness can/will result in marked enhanced MRADL performance or mobility or are needed for proper power mobility device functioning. There is no indication the member has skin breakdown and/or could not respond to standard cushions/rests. These items are convenience items and not medically necessary. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvean electronic connection (E2311), expandable controller (E2377), harness (E2313), a positioning seat cushion (E2605) and a positioning back cushion (E2613) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an epidural injection provided on October 16, 2019.
You asked the Plan to pay for epidural. You say that you are on a fixed income and cannot afford this. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because you were enrolled
in a hospice program on this date of service and therefore the Plan is not responsible for payment of this claim.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
You were under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we
decided that the Plan does not have to pay for an epidural injection provided on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction (92015) provided November 19, 2019.
You asked the Plan to pay for the refraction. You say that you are requesting reconsideration of the denial of
coverage. The Plan denied your request. The Plan says this service is not a covered benefit.
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 plan allows 1 routine eye exam a year and $100 towards the
purchase of 1 pair of eyeglasses or contact lenses.
We looked at the file and the Plan's rules. The plan does not cover for refraction. Based on this information, we
decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the
Plan does not have to pay for eye refraction (92015) provided November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on August 29, 2019 through August 30, 2019.You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed without the required G0 condition code causing the entire claim to deny.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 the outpatient hospital services are not supported in the record. Specifically, these services were billed without the required G0 code. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on August 29, 2019 through August 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are available in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decidedthat the Plan does not have to pre-approvemedical services to be provided by an out-of-network (OON) provider.
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 the enrollee currently has many unstable conditions which warrant close physician monitoring. She has also made good progress in therapy and would likely be able to tolerate three hours per day.The Plan denied your request. The Plan says this member is medically stable and his medical management does not require a continued inpatient stay.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee suffered a recent stroke. The stroke involved the left PCA/MCA territories and resultant deficits include cognitive, and mobility deficits. She currently has no fever and requires maximal assistance for mobility and lower body daily living activities. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician oversight. In this case, the member is mostly MAX assist for functional transfers and ADL's and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF level of 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that SNF care is needed.The Plan denied your request. The Plan says the enrollee does not need to be treated by a skilled nurse or therapist on a daily basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted on 3/12 due to a fall and was found to have a UTI. She was treated and stabilized. This patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not have a complex wound care or other SNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter 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 the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95908) and needle
electromyography (95886) provided on August 1, 2019.
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these
services are not supported by the medical record.
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 95908 is Nerve conduction studies; 3-4 studies.
The CPT Code Manual definition of code 95886 is Needle electromyography, each extremity, with related
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List
separately in addition to code for primary procedure).
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 nerve conduction studies and needle
electromyography. Our reviewer says that CPT code 95908 does not meet criteria for billing or reimbursement
consideration. The medical records provided does not include documentation of a Nerve conduction studies; 3-
4 studies, therefore the service cannot be verified. Our physician reviewer found CPT code 95886 does not
meet criteria for billing or reimbursement consideration. CPT code 95886 is an add-on code and requires the
primary procedure code to be reimbursed in order for CPT 96886 to be considered for reimbursement. In this
case CPT code 95908 was billed as the primary procedure but was not reimbursed by the health plan because
the submitted medical documentation did not corroborate that 95908 was performed.
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 nerve conduction studies and needle electromyography. have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95908) and needle electromyography (95886) provided on August 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facial transplant.You asked the Plan to pre-approve the facial transplant. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says facial transplants are considered experimental.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 facial transplant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found facial transplantation is not a widely-accepted reconstructive technique for the management of your condition. Facial transplantation may be considered investigational 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 of the facial transplant have not been met. Therefore, we decided that the Plan does not have to pre-approve a facial transplant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
You asked the Plan to pre-approve the percutaneous vertebral augmentation. You say that the member has
severe pain which limits function, mobility and quality of life. The Plan denied your request. The Plan says the
member has not had a recent MRI and does not meet Medicare coverage criteria.
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 percutaneous vertebral
augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found recent literature shows this procedure is not effective and
conservative treatment is most appropriate.
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 percutaneous vertebral augmentation have not been met. Therefore, we
decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services provided on October 24, 2019.You asked the Plan to pay for eye refraction services. You say that you feel that you were given wrong information because you were told by a plan representative that all of the requested providers were covered by the plan.The Plan denied your request. The Plan says refractive services are not covered under your benefit plan unless rendered by the listed Providers. 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 provided by a listed provider.We looked at the file and the Plan's rules. refraction services are only covered when provided by a participating plan provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction services have not been met.Therefore, we decided that the Plan does not have to pay for eye refraction services provided on October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral upper eyelid blepharoplasty and blepharoptosis
repair for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary, and will have
significant benefit. The Plan denied your request. The Plan says this is 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 the surgery. Our reviewer says that the
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer
found [state the medical finding(s) upon which the physician based his/her conclusion]
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve bilateral upper eyelid blepharoplasty and blepharoptosis repair for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.You asked the Plan to pre-approve the additional routine transportation trips. You say that you have dialysis 2 times a week and need transportation to your appointments.The Plan denied your request. The Plan says the benefit for routine transportation has been exhausted.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way routine trips. We looked at your request, the records in the case file, and the rules. The records show that you have received coverage for 24 one-way routine transportation trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips