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

We decided that the Plan does not have to pre-approve x-rays of left tibia and fibula (73590) x-ray of bilateral pelvis (73552) and x-ray of left knee (73562) to be provided by an in-network tertiary provider.
You asked the Plan to pre-approve the diagnostic services. You say that this doctor has seen you every 6 months so you would not have another infection. This is the second time you had to appeal for treatment with this doctor. The Plan denied your request. The Plan says enrollee does not meet tertiary level of care for x-rays. The same care can be safely performed by a provider at a lower, non-urgent level of care.
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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the diagnostic services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case
the record indicates that the enrollee had a complex surgical history having undergone a status post femoral modular endoprosthesis with total knee component procedure. Imaging at one year demonstrates stable fixation and a good result. The provided record does not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested procedure for the enrollee's clinical situation. The routine x-rays can be performed at a non-tertiary level provider facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the diagnostic services. Therefore, we decided that the Plan does not have to pre-approve x-rays of left tibia and fibula (73590) x-ray of bilateral pelvis (73552) and x-ray of left knee (73562) to be provided by an in-network tertiary provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Aircast (L4360) for the enrollee.
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says there are no medical issues with ankle or foot weakness or deformity.
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 item. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provider does not indicate that the enrollee has a deformity that requires stabilization. The record does not indicate that the requested device will benefit functionality. The elements of the coverage rule are not satisfied. 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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve an Aircast (L4360) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on March 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office services. You say that the enrollee was seen for an injection. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office services provided on March 26, 2021 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you have hypotension and need immediate respiratory care. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for Coronavirus pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99292) provided to the enrollee on December 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99292-25 (4 Units) remains 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 99292 is "additional 120 minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management service (Current Procedural Terminology (CPT) code 99291)." We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentations states "Critical Care Time: 120 minutes." Per the CPT guidelines for Critical Care Time of 105-134 minutes spent, the following CPT codes should be reported as ""99291 x1 and 99292 x2." In this case, CPT 99292 should be reported with two units in addition to CPT 99291 with one unit. We looked at this coder's review, the file, and Medicare rules. 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 critical care services (99292) provided to the enrollee on December 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram services provided on January 28, 2021.
You asked the Plan to pay for the rhythm electrocardiogram services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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, we have confirmed that code 93042 for the rhythm electrocardiogram services has a bundled relationship with code 93010 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram services provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are bedridden from muscle and
bone weakness. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemotherapy infusion service provided on March 9, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the service provided.
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 $300 copayment for each Medicare-covered outpatient hospital visit for certain drugs and biologicals that you cannot give yourself.
You have been asked to pay a $216.96 copayment for the chemotherapy infusion service provided at the outpatient hospital. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 chemotherapy infusion service provided on March 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from March 4, 2021 to April 30, 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 the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that home health claims must be billed with a HIPPS and treatment authorization code. We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid HIPPS and treatment authorization code. 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 home health services rendered from March 4, 2021 to April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi.
You asked the Plan to pre-approve Imfinzi. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Imfinzi. Our reviewer says that the medication is not medically necessary. Our physician reviewer found this enrollee has not yet had follow-up imaging after chemoradiation. The service is not reasonable or 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clarifix cryotherapy.

You asked the Plan to pre-approve Clarifix cryotherapy. You say that you have been struggling with chronic rhinitis for the past 7 years. It is getting worse. You have been seeing the ear, nose throat specialists within the Plan for this issue but none of them have been able to help you. The Plan denied your request. The Plan says there is insufficient evidence to show that this therapy is as safe as standard services and/or therapies or provides better long-term outcomes than current standard services and/or therapies.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Clarifix cryotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Clarifix cryotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on February 1, 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 the services were not medically necessary.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found there is no evaluation after March 9, 2021 in the submitted records. The documentation shows the enrollee is on insulin four times per day and adjusts insulin doses according to blood glucose levels, but there is no documentation of an evaluation within the last six months. The criteria are therefore not met and the services were 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on February 2, 2021.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your
request. The Plan says this code 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 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 records do not show that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the power wheelchair (CPT code K0800) and safety flag (CPT code K0108), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee is able to perform all the mobility related activities of daily living without assistance. You state the enrollee does have Home Health services (Recovery Health) which come in to help the enrollee with feeding, dressing, grooming, and bathing on a regular basis but are not present 24/7. You state, regarding the walking of household distances unaided, the enrollee reminds you that they are using a walker and therefore is aided. You state the enrollee does have did great difficulty with mobility and has had multiple falls in their home. The Plan denied your request. The Plan says that the Medicare rules have not been met.
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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pre-approve the power wheelchair (CPT code K0800) and safety flag (CPT code K0108), for the enrollee.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427, A0425) provided on March 21, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this service was necessary, and you cannot afford this bill as you live on a fixed income. The Plan denied your request. The Plan says the copayment for this claim was processed correctly.
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 $250 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $250 copayment for the ambulance services. 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 emergency ambulance transportation services (A0427, A0425) provided on March 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331) provided on April 22, 2021.
You asked the Plan to pay for the dental service. You say that this service was necessary to save your tooth. You say that you were in severe pain. You also say that you do not understand why this is not covered. The Plan denied your request. The Plan says the treatment of a root canal obstruction is not listed as a covered service.
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 treatment of root canal obstruction
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331) provided on April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from October 12, 2020, through October 22, 2020.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 physical therapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from
October 12, 2020, through October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have the same issues that one with diabetes would have. 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 pre-approve foot orthotics.