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

We decided that the Plan does not have to pay for a pneumatic compression device provided on February 26, 2021.
You asked the Plan to pay for a pneumatic compression device (E0676). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this device was used to prevent blood clots after surgery therefore excluded from coverage.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intradialytic Parenteral Nutrition (IDPN).
You asked the Plan to pre-approve IDPN. 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 follows Medicare rules. Medicare rules say that coverage of nutritional therapy as a Part B benefit is provided under the prosthetic device benefit provision which requires that the patient must have a permanently inoperative internal body organ or function thereof. 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 IDPN. Our reviewer says that the services are not medically necessary. Our physician reviewer found Medicare rules only cover enteral and parenteral nutrition therapy only if a patient has a permanent problem with the digestive tract (stomach and intestines) where they are not able to take in or absorb nutrients. The documentation does not indicate that the enrollee has a permanent problem with her digestive tract. The enrollee does not meet the coverage criteria detailed in the NCD.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to pre-approve Intradialytic Parenteral Nutrition (IDPN).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services provided to the enrollee on April 1, 2021.
You asked the Plan to pay for the services. You say that the in-network surgeon chose an out-of-network anesthesiologist. The Plan denied your request. The Plan says that the services are not urgent or emergent, nor were they approved in advanced.
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 follows these rules. The enrollee was referred for the services by a contract surgeon. The file does not show that the plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the plan. The plan has not responded to the claim that the ordering provider was in-network for these services. Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on April 1, 2021.
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 pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have 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 36 one-way transportation trips when each one-way trip does not exceed 50 miles. 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 mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dmission to a long term acute care hospital (LTACH) for the enrollee.
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 there are no clinical condition that can't be appropriately treated in the current hospital or a lower level of care.
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 the enrollee was admitted with peritonitis. The enrollee is not on ventilator and does not ave complex wound care requirements. The enrollee continues to receive acute care services, including intravenous antibiotics and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve dmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve a SI joint injection. You say that the services are necessary. The Plan denied
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 a SI joint injection. 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, there is no documentation on physical examination of tenderness to the
SI joint and no mention of SI provocative testing being completed with positive findings. Of note the medical
record indicates the provider suspects disc herniation and moderate stenosis at L4-L5 as the source of her pain.
The review has determined that the requested sacroiliac joint injection is not medically reasonable or 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 a SI joint injection have not been met. Therefore, we decided that the Plan does
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vascular mat therapy received on February 17, 2021.
You asked the Plan to pay for the therapy. You say that this should be covered. The Plan denied your request. The Plan says the provider has opted out of participating in Medicare programs.
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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for vascular mat therapy received on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization
or other adverse health outcomes; and must require intensive care coordination.
We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to preapprove
special supplemental benefits for the chronically ill that includes transportation for non-medical needs,
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home
assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a precision attachment, by report (D5862).
You asked the Plan to pre-approve a precision attachment. You say that you need the dental services approved
in order to eat. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
precision attachment, by report (D5862).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services received from November 11, 2020 to November 13, 2020.
You asked the Plan to waive the copayment for the services. You say that you do not remember signing anything for admittance nor for discharge. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
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 emergency services. You have been asked to pay a $50 copayment for the services. The service falls within the emergency services 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 emergency room services
received from November 11, 2020 to November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 pressure-reducing mattress for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the enrollee is wheelchair bound and at high risk for falls. The Plan denied your request. The Plan says there are none of the covered conditions listed.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee has multiple stage II pressure ulcers located on the trunk or pelvis which have been treated in a comprehensive program or large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. 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 group 2 pressure-reducing mattress for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99223, 99232, 99153) provided from April 7, 2021, to April 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that A type 1 Excludes note is a pure excludes note. An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together. Medicare rules also say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. We looked at the file and Medicare rules. In this case diagnosis code I49.5 has an "Excludes1" note for diagnosis code R00.1. This means that these two diagnosis codes are not allowed to be billed together. Additionally, we find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. 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 services (99223, 99232, 99153) provided from April 7, 2021, to April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF 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. 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided to the enrollee on March 6, 2021.
You asked the Plan to pay for the testing. You say that this laboratory is the only provider of this test. The Plan denied your request. The Plan says the request represents apparent claim unbundling and is not allowed.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided to the enrollee on March 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended pharmacogenomic testing panel provided on February 17, 2021.
You asked the Plan to pay for the testing panel. You say that these tests have been reviewed by Palmetto and have been assigned a Z-code. This means they must be covered. The Plan denied your request. The Plan says this panel must be billed with only one code.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to confirm that Medicare coverage criteria have been met. In this case, the only documentation submitted were the results of this testing. A progress note from the ordering physician was not provided to confirm that medical necessity criteria were met. Therefore, we decided that the Plan does not have to pay for the extended pharmacogenomic testing panel provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 15, 2021.
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 the services rendered by non-participating 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 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 physician services provided to the enrollee on
February 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 4, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you fainted at a restaurant and the ambulance was called to treat you and you were advised to be transported to the hospital, but you refused. You say that subsequently, your son took you to the hospital for treatment. The Plan denied your request. The Plan says ambulance services without transport is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services provided on June 27, 2020.
You asked the Plan to pay for the ER services. You say that the enrollee was not deceased on the date of service. The Plan denied your request. The Plan says payment was recouped as the date of service billed is after the enrollee's official date of death.
The Plan must follow Medicare rules. Medicare rules say that payments made for services rendered after date of death are not permissible. The Medicare records have confirmed that the enrollee's official date of death is listed as June 22, 2020. Since these services were rendered after that date, payment is not permissible. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided on June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services rendered on February 11, 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 procedure code G0402 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 G0402 is initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment. We find that CPT code G0402 is not supported in the medical record. Specifically, the documentation shows that the services were telehealth and this code is not appropriate for telehealth services. 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 telehealth services rendered on February 11, 2021.