Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from July 19, 2019 to October 7, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from July 19, 2019 to October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation services provided on March 4,
2019.
You asked the Plan to pay for the inpatient consultation 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, the CPT Code Manual definition of code 99254 is inpatient consultation for a new or established
patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and
Medical decision making of moderate complexity. Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high
severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit.
We find that CPT code 99254 is not supported in the medical record. Specifically, this code has a status code of
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the inpatient consultation services have not been met. Therefore, we decided that the Plan does not
have to pay for the inpatient consultation services provided on March 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from August 2, 2019 to October 21, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from August 2, 2019 to October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the services are not medically necessary. Our physician reviewer found the enrollee is currently
undergoing treatment at an acute care hospital (ACH) for multiorgan failure and shock. The enrollee was
intubated/ventilated, but has since been extubated and is no longer on a ventilator. The enrollee has been started
on hemodialysis. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage
in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute
services are required.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS HF system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered under the current Medicare Category B investigational device
exemption requirements.
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 system. Our reviewer says that the
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer
found in this circumstance therapy change based on data obtained from a CardioMEMs device has been
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.
Moreover, concerns have been raised about potential bias in this trial calling into question the results.
Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and
not recommended in current guidelines for the treatment of heart failure. This device should still be considered
experimental and investigational.
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 system have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CardioMEMS HF system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on July 23, 2019
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing the denial of payment for the office visit on July 23, 2019. You have submitted medical records to prove medical necessity for services. The Plan denied your request. The Plan says the claim was denied for no valid referral for this service. The rules say that a Medicare health plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through the network. The health plan must arrange specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet a member's medical needs.
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 a domiciliary or rest home visit (99335) provided on July 23, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 monitoring device.
You asked the Plan to pre-approve a Dexcom G6 monitoring device. You say that the Dexcom G5 has not worked properly for the last few months. The Plan denied your request. The Plan says that you have already been supplied with a continuous glucose monitor.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a Dexcom G5 monitoring device. A Dexcom G5 monitoring device serves the same purpose as a Dexcom G6 monitoring device. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 monitoring device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 1, 2019 by out of network provider,
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 physician services provided on August 1, 2019 by out of network provider,.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on August 28, 2019 by the out
of network provider.
You asked the Plan to pay for an office visit. You say that the provider is not responsible to request
authorization for a Medicare patient to whom he renders services. Regardless of your decision whether there
was authorization or not, the patient evidently required the medical care received from the provider. The Plan
denied your request. The Plan says the provider is a non-network provider who does not work
with the member's health plan, and the member self-directed for services. No prior authorization for any
services was noted. The member's primary care physician did not refer for services. The health 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 emergency situation, 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 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 an office visit (99214) provided on August 28,
2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 1, 2019 by an out of network provider.
You asked the Plan to pay for the out-of-network services. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 services at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 1, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for preventive medicine, group counseling services (99412) provided on August 14, 2019.
You asked the Plan to pay for the preventive medicine, group counseling services. You say that you are requesting reconsideration for the denial for coverage. The Plan denied your request. The Plan says the request exceeds the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the preventive medicine, group counseling services have not been met. Therefore, we decided that the Plan does not have to pay for preventive medicine, group counseling services (99412) provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual enema pump.
You asked the Plan to pre-approve the enema pump. You say that you need this item in order to avoid the need for an ileostomy. The Plan denied your request. The Plan says Medicare does not cover this type of enema pump.
The Plan must follow Medicare rules. Medicare rules say that enema pumps are non-covered as they do not fall into a covered benefit category. Although this may be appropriate, this is not a device that Medicare is allowed to cover. Therefore, we decided that the Plan does not have to pre-approve a manual enema pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that the services are 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. 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 inpatient mental health care. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 14, 2019 forward as the enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. 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 mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram on September 16, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that both mammograms were done at the hospital. You say that you are appealing the denial of payment. The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for each covered x-ray service including diagnostic mammograms at an in-network provider. You have been asked to pay $38.87, which is less than the standard $50 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic mammogram on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery and moderate anesthesia.
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary and not just a dental matter. The Plan denied your request. The Plan says you do not have a supplemental dental benefit for comprehensive dental services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve oral surgery and moderate anesthesia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 11, 2019 to June 14, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says services could have been provided in an outpatient observation setting.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the records do not show that the admitting physician expected the enrollee's treatment to span more than 2 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 11, 2019 to June 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with a small bowel obstruction. The enrollee is noted to have had a tracheotomy and feeding tube at presentation. It is unclear if the enrollee was on a ventilator prior to hospitalization, but he is on a ventilator at present. There is no clear documentation of weaning attempts and no evidence that the enrollee is to be decannulated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the incontinence products coded T4541 provided on September 3, 2019.
You asked the Plan to pay for the incontinence products. 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, the CPT Code Manual definition of code T4541 is incontinence product, disposable underpad, large, each. We find that CPT code T4541 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the incontinence products have not been met. Therefore, we decided that the Plan does not have to pay for the incontinence products coded T4541 provided on September 3, 2019.