Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical therapy (PT) re-evaluation and continued treatment.
You asked the Plan to pre-approve the continued PT services. You say that the enrollee continues to have range of motion loss, weakness, and balance deficits which would benefit from continued therapy. The Plan denied your request. The Plan says the enrollee has not had appreciable improvement for the last few weeks/month and ongoing therapy is not likely to help her further.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 continued PT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee is a 73-year-old-female who has history of right quadriceps tendon repair on 03/06/20 and had 32 approved physical therapy visits from 3/20/2020 to 6/26/2020. PT notes from 06/25/20 stated that would benefit from further PT to improve strength and stability to return to her stair climbing and ambulation on uneven surfaces to prior level of function. She has exhausted her approved therapy visits and the therapist and provider are requesting continued PT. Based on review of the available records, the patient does not meet criteria for continued physical therapy. It is not medically necessary based on the fact that the patient seems to have plateaued with no further functional improvement. According to the provider, the patient has shown good improvement in function, but this is not reflected in her functional outcome score LEFS. The Numeric Pain Rating Scale is 1/10. There has been a reduction in complicating factors, such as pain, and she still has trouble with descent of stairs. The
documentation of her objective measures does not support continued PT for her clinical condition. Her condition is stable and skilled therapy is not required to maintain her current condition. She should be able to maintain her function with HEP. 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 continued PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve a physical therapy (PT) re-evaluation and continued treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat lift chair and mechanism.
You asked the Plan to pre-approve a power seat lift chair and mechanism. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of a power seat lift chair and mechanism.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed are met. We looked at the case file and Medicare rules. The documentation provided does not clearly indicate that you are completely unable to stand up from a standard arm chair or that you have severe knee or hip arthritis. Based on this information, we decided that Medicare rules for coverage of a power seat lift chair and mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat lift chair and mechanism.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Logisticare mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan 
denied your request. The Plan says the distance (avoiding highways, tolls, and ferries) is 119 miles, which 
exceeds the limit. 
 
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 routine transportation up to 50 miles one-way each trip.  
 
The requested trip is 119 miles, which exceeds the 50 mile one-way trip limit.Based on this information, we 
decided that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional Logisticare mileage.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Cxbladder testing provided on December 27, 2019. 
 
You asked the Plan to pay for Cxbladder test. You say that you disagree with the Plan's denial of this testing. 
The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this 
test is not covered according to the Plan's coverage guidelines. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its denial of payment for this test is 
correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for Cxbladder testing 
provided on December 27, 2019.
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 additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.
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 transportation trips per year. We looked at your request, the records in the case file, and the rules. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code J7040 provided on January 21, 2020. 
 
You asked the Plan to pay for CPT code J7040. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Medicare says the NDC code must be correct. In this case, the claim 
was billed with the incorrect NDC and CPT code J7040 is not payable as billed. The Plan will accept a 
corrected claim for reconsideration. Based on this information, we decided that Medicare rules for coverage of 
CPT code J7040 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 
J7040 provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive
interface, (e.g., mask, chest shell) (E0466), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied
your request. The Plan says the DME is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer
found coverage criteria for a home ventilator are not met. There is no evidence of failure of BiPAP. Medicare
does not cover a home ventilator when used as BiPAP. A home ventilator is not medically necessary, and the
denial is upheld.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466),
for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve chiropractic manipulative treatment (98940). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan?s 
denial. The Plan denied your request. The Plan says that medical necessity for the requested chiropractic 
service has not been established. 
 
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.  Therefore, we decided that the Plan has to pre-approve chiropractic 
manipulative treatment (98940).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on 
October 17, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records signed 
by the ordering physician stating exactly what tests were to be performed. The submitted  Laboratory 
Requisition indicates that Toxicology Profile R019 Panel was requested. The submitted documentation does 
not itemize what tests are included in this panel. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded 80307 and G0482 provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination sit-to-stand frame/table system with seat lift feature, with or without wheels.
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your request. The Plan says Medicare does not consider standing tables to be primarily medical in nature.
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. Therefore, we decided that the Plan does not have to pre-approve combination sit-to-stand frame/table system with seat lift feature, with or without wheels.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code J1756 provided from November 4, 2019 to 
November 29, 2019. 
 
You asked the Plan to pay for CPT code J1756. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim is not payable as it was not billed with an 
appropriate primary and secondary diagnosis code. Therefore, we decided that the Plan does not have to pay for 
CPT code J1756 provided from November 4, 2019 to November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge (99217) provided on February 11, 
2020. 
 
You asked the Plan to pay for the observation care discharge. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this service is included in another 
service provided by the same provider. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]) 
 
We find that CPT code 99217 is not supported in the record. Specifically, the record indicates the member was 
admitted inpatient from an observation status. In this case, it is inappropriate to report observation discharge 
codes separately. Based on this information, we decided that Medicare rules for coverage of the observation 
care discharge have not been met. Therefore, we decided that the Plan does not have to pay for observation care 
discharge (99217) provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 fractions of AccuBoost Brachytherapy and related services 
(77236, 77280, 77290, 77300, 77316, 77317, 77318, 77336, 77370, 77470, 77770, 77771, & 77772). 
 
You asked the Plan to pre-approve the Brachytherapy. You say that this treatment is medically necessary. The 
Plan denied your request. The Plan says that coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the Brachytherapy. Our reviewer says 
that the requested radiation therapy is medically necessary. Our physician reviewer found that guidelines do 
not discuss Accuboost specifically but explicitly state that boost therapy can be delivered with electrons, 
photons or brachytherapy. Given that brachytherapy is an accepted modality for boost treatment, the treatment 
should be considered within accepted standards of care and therefore meeting standard medical necessity 
criteria. 
 
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 Brachytherapy have been met. Therefore, we decided that the Plan has to 
pre-approve 5 fractions of AccuBoost Brachytherapy and related services (77236, 77280, 77290, 77300, 77316, 
77317, 77318, 77336, 77370, 77470, 77770, 77771, & 77772).  
.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator procedure (C1897, 64555, 
C1778, 76942). 
 
You asked the Plan to pre-approve the procedure. You say that the procedure is medically necessary. The Plan 
denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered when 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 the procedure. Our reviewer says that 
the requested spinal cord stimulator is not medically necessary. Our physician reviewer found to justify a nerve 
stimulator surgery one must have failed prior treatments, must have successfully passed a psychological 
assessment and must have had a trial of the stimulator prior to permanent placement, each of which were not 
documented. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator procedure (C1897, 64555, C1778, 76942).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on September 7, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says they have made several attempts to obtain proof of timely filing of this claim submission 
and have yet to receive a response from the provider. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until December 5, 2019. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided to the enrollee on September 7, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care for the enrollee from March 8, 2020 through March 9, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the additional days were medically necessary. The Plan denied your request. The Plan says the addition days were 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 pay for inpatient hospital care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the additional inpatient days (March 8, 2019 through March 9, 2019) were not medically necessary. In this case, the member remained in the hospital over the weekend of March 7, 2020 through March 9, 2020 waiting for reassessment from his assisted living facility prior to transfer back to that 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care for the enrollee from March 8, 2020 through March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased on January 20, 2020 from an out-of-network
provider.
You asked the Plan to pay for the DME. You say that the sling given by the provider was not effective and you
purchased one at an out-of-network provider. The Plan denied your request. The Plan says it was determined
that you did not receive a referral from your Primary Care Physician to this provider, instructing you to obtain
equipment for your health condition.
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 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 DME purchased on January 20, 2020 from an
out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive eye examination (92014) provided December 11, 2019.
You asked the Plan to waive the copayment for the vision services. You say that you went for an evaluation for a blepharoplasty. The provider was insisting on performing an eye exam that had just been done by another provider. After this discussion, there were no services rendered. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied.
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 $20 copay for exams to diagnose and treat diseases and conditions of the eye for Vision care. You have been asked to pay $20 copay for exams to diagnose and treat diseases and conditions of the eye. The vision services fall within the Vision care 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 comprehensive eye examination (92014) provided December 11, 2019.