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

We decided that the Plan does not have to pay for a segmented pneumatic compression device (E0651).

You asked the Plan to pay for pneumatic compression device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this item does not meet Medicare coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that coverage of a PCD for CVI requires a six-month trial of conservative therapy meeting all of a set of criteria.

We looked at the file and Medicare rules. Although the record includes a certificate of medical necessity stating that a six-month trial of conservative therapy took place, it does not describe that this trial met all of the criteria required by Medicare for coverage of the billed PCD. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a segmented pneumatic compression device (E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM and supplies (CPT code(s): K0553 and K0554), for the enrollee.
You asked the Plan to pre-approve the services. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the enrollee is not consistently testing the blood sugar four or more times a day and is not making frequent insulin adjustments based upon the testing result. The elements of the LCD are not satisfied. The requested service cannot be recommended. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM and supplies (CPT code(s): K0553 and K0554), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient visit provided on March 11, 2020.
You asked the Plan to pay for a hospital outpatient visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the surgery. 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 hospital outpatient visit provided on March 11, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are being met in the current setting.
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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is documentation that the enrollee requires skilled nursing services and skilled therapy services on a daily basis. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued services in the acute inpatient rehabilitation facility appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from March 24, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 physician reviewer found that it was not expected this enrollee would improve in a reasonable period of time for the dates in question as they did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. This enrollee did not show any abnormal behaviors or any symptoms which would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as they did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as they were not a danger to themselves or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of March 24, 2021, forward as this enrollee was not shown to be a danger to
themselves or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This patient was not showing any aggressive behaviors or any treatment required for acute threats of safety. 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 continuation of inpatient mental health care provided to the enrollee from March 24, 2021, forward.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on September 3, 2020.
You asked the Plan to pay for psychotherapy. You say that the provider depends on hospital staff to verify eligibility and obtain proper authorization. You say that the services were medically necessary, and the claim should be processed for payment. The Plan denied your request. The Plan says services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 psychotherapy provided by an out-of-network provider on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says LTACH coverage criteria has not been met.
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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the health Plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for a sacral decubitus. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had.

You asked the Plan to waive the copayment for the primary care office visit. You say that you should not have
a copayment for this visit since it was your annual wellness visit. The Plan denied your request. The Plan says
it already paid for an annual wellness visit for you. You are only permitted to have one annual wellness visit once 
every 12 months. Therefore, you were not entitled to a 100%-covered annual wellness visit. Because this primary 
care office visit was prior to this date, the regular office visit copayment applies.

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 $10
copayment for primary care office visits.

You have been asked to pay a $10 copayment for the primary care office visit. Because you were not eligible
for a 100% covered annual wellness visit at the time of this service, this copayment applies. 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 primary care office visit you had.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided January 7, 2020, and November 16, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that the Plan should provide some benefit for the service. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for 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 pay for the periodontal maintenance (D4910) provided January 7, 2020, and November 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 6, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you believe the MRI was unnecessary due to your primary care physician not seeing you during a crucial episode, but the neurologist ordered it for your safety. 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 $225 copayment for diagnostic radiology other than CT scans performed by a provider other than your primary care physician. You have been asked to pay a $225 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the MRI was performed. 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 MRI provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery (22869).
You asked the Plan to pre-approve a Vertiflex Superion device. You say that you have chosen to perform this particular procedure because this procedure is a minimally invasive procedure compared to an open spinal fusion surgery. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare. There is not enough studies on Vertiflex Superion to show it is safe and effective.
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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device placement surgery (22869).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on October 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is documentation that the enrollee requires skilled nursing services and skilled therapy services on a daily basis. Based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued services in the acute inpatient rehabilitation facility appear appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mohs micrographic technique (17313 and 17314) provided on October 23, 2020.
You asked the Plan to pay for the Mohs micrographic technique. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 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 Mohs micrographic technique. Our reviewer says that CPT code 17313 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation of pathology findings for the first stage specimen to validate a Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks being performed on October 23, 2020, therefore, this service cannot be verified. Our reviewer found CPT code 17314 does not meet criteria for billing or reimbursement consideration. CPT 17314 is an add-on code and is not separately reimbursable when the primary procedure code does not meet criteria for reimbursement. 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 Mohs micrographic technique have not been met. Therefore, we decided that the Plan does not have to pay for the Mohs micrographic technique (17313 and 17314) provided on October 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits.

You asked the Plan to pre-approve 3 additional home health skilled nursing visits. You say that this is necessary because the enrollee has a new pressure injury. The Plan denied your request. The Plan says the information needed to show this is necessary has not been received.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 3 additional home health skilled nursing visits. Our reviewer says that the documentation does not support that the member requires skilled nursing services. Our physician reviewer found the member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The wound care is not complex in nature and there have not been any complications with healing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits.