Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay fora thorax CT Scan (71250) provided on September 10, 2019.You asked the Plan to pay forthe CT Scan. You say that you would like reconsideration based on the records submitted.The Plandenied your request. The Plan says that procedure code 71250 was denied as the column II code to the column I code 71260 paid previously.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. Specifically,the Plan has not included documentation regarding the Column I procedure to substantiate the denial.Therefore, we decided that the Plan has to pay fora thorax CT Scan (71250) provided on September 10, 2019.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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on August 2, 2019.You asked the Plan to pay for thepsychiatric diagnostic evaluation. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 servicesat 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 a psychiatric diagnostic evaluation provided on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe manual swingaway control interface coded as E1028 and the cushioned headrest coded as E0955 to be providedwith the approved power wheelchair.You asked the Plan to pre-approvethe swingaway control interface and cushioned headrest. You say that this denial is not consistent with the facts. The enrollee does have current wheelchair that no longer meets her needs which will be picked up when the new wheelchair is provided. The enrollee is a double amputee and cannot give up the current chair until the new one is approved and delivered.The Plan denied your request. The Plan says on review, it was found that the criteria for the Group 2 wheelchair and most of the requested accessories are met. However, both E0955 and E1028 are included in the charge for other approved codes and cannot be separately authorized. The Plan must follow Medicare rules. Medicare rules say that code E1028 cannot be billed in addition to E1020 as the latter includes the function of the former. In addition, a headrest is not considered medically necessary if provided with a wheelchair that includes a captain's chair seat. In this case, code E1020 was requested and approved by the Plan. As such, approval cannot be made for E1028 as this is included in payment for E1020. In addition, the code that was requested and approved for the power wheelchair base was K0842, the code description of which includes a captain's chair. This means that as coded, E0955 could not be separately approved along with K0842.Therefore, we decided that the Plan does not have to pre-approvethe manual swingaway control interface coded as E1028 and the cushioned headrest coded as E0955 to be provided with the approved power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan with CT scan.
You asked the Plan to pre-approve a PET scan with CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 PET scan with CT scan. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has complaints of upset stomach for a month. No abdominal examination was recorded in the physical examination. Alkaline phosphatase was minimally elevated (less than 2 x ULN). No other imaging was performed or requested. The enrollee does not meet criteria for the requested 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 a PET scan with CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan with CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbath/shower chair, with or without wheels, any size (E0240) provided on September 11, 2018.You asked the Plan to pay forthe bath/shower chair. You say that you are appealing for reconsideration of the denied charges for a Continuous Passive Motion (CPM) stretching device.The Plan denied your request. The Plan says the claim submitted is coded as a bath/shower chair and it is not covered by the Plan or Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. You have had knee joint replacement surgery. You are requesting payment for a CPM; however,the claim submitted was coded as E0240 Bath/shower chair. Your doctor states in your medical record that you have had knee joint replacement surgery. Medicare views bath/shower chairs as primarily hygienic equipment, not primarily medical in nature.Therefore, we decided that the Plan does not have to pay forbath/shower chair, with orwithout wheels, any size (E0240) provided on September 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971) and foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (L3170) provided to the enrollee on September 20, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support the services.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1971) and foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (L3170) provided to the enrollee on September 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on September 5, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that you confirmed the member's benefits and believe that non-emergency transport is a covered benefit if medical necessity is met. The Plan denied your request. The Plan says they have no record of the non-participating provider calling to verify member benefits and coverage.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on September 5, 2019. The documentation states that a wheelchair van would not be appropriate because the patient could not sit for the duration of transport time. There is no documentation that a stretcher van would have been inappropriate. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on September 5, 2019. The documentation does not support that the ambulance transport on September 5, 2019 was medically reasonable and necessary for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa 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 the requested drug is subject to step therapy.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug is not medically reasonable or necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 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 Euflexxa injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee orthosis.You asked the Plan to pre-approvethe knee orthosis. The Plan denied your request. ThePlan says you do not have objective joint or ligament instability.The Plan follows Medicare rules. Medicare rules say that knee orthoses are only covered under certain medical 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 the knee orthosis. Our physician reviewer found that you have longstanding right knee pain from advanced osteoarthritis. The document notes no past history of a surgical procedure. You were noted to have no history of falls, or needing of transfer help or an assistive device. You have no sensory or motor deficits on exam, or gait imbalance. The documentation does not reveal a recent injury to or a surgical procedure on the knee(s). You are noted to be ambulatory, but there is no objective evidence of knee instability. Therefore, the requested orthosis 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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approvea knee orthosis.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided February 23, 2019 through February 26, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the care provided at the direction of the treating physician was appropriate, reasonable and rendered at the appropriate level of care. The Plan denied your request. The Plan says that the care provided did not meet inpatient level of care criteria. The criteria requires that the patient fail to improve under an observation level of care at the hospital.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found on initial evaluation that the blood pressure was 205/83. Physical exam was notable for increased dizziness with positional changes. The enrollee was treated with IV fluids and admitted. The enrollee underwent magnetic resonance imaging (an MRI) of the brain, echocardiogram, carotid ultrasound and had evaluations by physical therapy (PT)/occupational therapy (OT). The enrollee underwent cardiac monitoring and correction of her electrolytes. The enrollee's condition stabilized and improved and she was considered medically stable for discharge on February 26, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided February 23, 2019 through February 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0648) and suspension sleeve (L2397) provided to the enrollee on August 13, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), lumbar-sacral orthosis (L0648) and suspension sleeve (L2397) provided to the enrollee on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete lower denture (D5120).You asked the Plan to pre-approvethe dental item. You say that the enrollee accidentally threw away her lower denture. You say that the enrollee is on a fixed income and is would be impossible for her to cover the complete out of pocket cost. You also say that the enrollee needs the lower denture in order to eat properly.The Plan denied your request. The Plan says the frequency limit for dentures 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 dentalbenefit in excess of Medicare coverage and dentures are a covered service, the frequency limit has been reached. The record shows that you last received on April 22, 2019.Therefore, we decided that the Plan does not have to pre-approvea complete lower denture (D5120).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (99213) provided on August 8, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers that could provide the services. The services were not emergent or preauthorized.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health services (99213) provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support the services.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on September 3, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services provided August 13 to October 8, 2019.  You asked the Plan to pay forthe outpatient health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee is not eligible for Medicare payment.The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC's) are not eligible for enrollment in the Medicare program. We looked at the file and Medicare rules. Theprovider is listed as a LPC. Based on this information, we decided that Medicare rules for coverage of the outpatient health services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services provided August 13 to October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on September 13, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on September 13, 2019.