Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy (PBT) with image-guided radiation therapy.

You asked the Plan to pre-approve PBT. You say that other treatments would not be acceptable, and this proton therapy plan would have about one-tenth of the radiation going to the enrollee's heart. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this proton beam therapy is not medically necessary and not in keeping with guidelines.

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 PBT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found with this enrollee 3-dimensional (3D), intensity-modulated radiation therapy (IMRT), and proton therapy (PBT) result in average (mean) cardiac radiation doses of roughly 11Gy, 7Gy, and 1Gy respectively. There is a plausible benefit of proton therapy given that the other non-proton based treatments do not meet consensus constraints for mean dose. Mean doses of 7 to 11Gy are unacceptable high if there is a means to reduce the exposure. The reduction in mean heart dose with proton therapy in this enrollee is significant. Proton therapy will invariably reduce heart and lung exposure - but not always in a clinically meaningful way - and a 3D or IMRT plan can often be made to look better or worse depending on beam arrangement, planning parameters, and other factors. Nevertheless, it is apparent that the non-proton plan can be considered unacceptable, and that the proton plan would be markedly better. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBT have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy (PBT) with image-guided radiation therapy.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on
December 19, 2020.

You asked the Plan to pay for the CGM supplies. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the documentation is missing required information.

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 does not contain relevant medical records which support medical necessity for the supplies provided
in this case. Review of the file shows that the documentation does not include a claim on file from the ordering
provider for the billed date the billed supply code was ordered. The record shows that the Plan made several
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not
have to pay for the continuous glucose monitor (CGM) supplies provided on December 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 6, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 6, 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 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 requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with acute on chronic hypercapnic respiratory failure requiring high flow oxygen with intermittent BiPAP, and antibiotics. He appears to be improving and should only require short-term additional acute care services which can be safely be received at the current facility. He does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. The LTACH services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on April 5, 2020.
You asked the Plan to pay for moderate sedation services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this code may not be paid if furnished to a hospital inpatient or patients in a hospital outpatient.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate Place of Service code. We find that the place of service is incorrect. Based on this information, we decided that Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services provided on April 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for. respiratory failure, atrial fibrillation, and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is not medically necessary because it is experimental/investigational.

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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain with neurogenic claudication due to spinal stenosis and scoliosis. The enrollee has tried physical therapy, epidural steroid injections, and radiofrequency ablation of the medial branches. The enrollee has medication management and has had a prior lumbar laminectomy. The requested procedure is considered experimental/investigational. It is not endorsed by either the North American Spine Society or the American Orthopedic Association. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 22, 2020 and billed under claim 820202110291519.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states that the medical records specifically show only 14 drug classes were tested. Therefore, this service was coded incorrectly. The records do not include definitive laboratory results for 22 or more drug classes to support the coding criteria for the code billed on date of service. There was a total of 14 drug classes counted from the laboratory results received.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed because the code billed is not supported by the number of drug classes actually tested. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on July 22, 2020 and billed under claim 820202110291519.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5298) received October 20, 2020.
You asked the Plan to pay for the hearing aid. You say that you are severely hearing impaired and require the hearing aids. The Plan denied your request. The Plan says you have exhausted your $1,000 hearing aid benefit allowance; therefore, any remaining balance is your responsibility.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to $1,000 towards covered hearing aids once every four years. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. The Plan has submitted evidence that $1,000 was applied towards a covered hearing aid on February 27, 2018. You were not eligible for coverage on this date of service. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5298) received October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a femur fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the specialist services provided by an out-of-network (OON) provider on October 22, 2020.
You asked the Plan to pay for the specialist services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that prior authorization was not obtained to seek out-of-network services
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The rules say that a plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations. We looked at your contract with the Plan. The contract clearly says that prior authorization may be required for physician/practitioner services. However, the contract also says you never need approval in advance for out-of-network services from out-of-network providers. As the Plans only denial reason is no prior authorization, we find that the Plan's contract does not clearly say prior authorization is required for out-of-network care. Therefore, we decided that the Plan has to pay for the specialist services provided by an out-of-network (OON) provider on October 22, 2020. This will apply your out-of-network cost share as your responsibility.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the extra heavy-duty wheelchair (K0007), cushions (E2602, E2612), and seat frame (E2201).
You asked the Plan to pay for the extra heavy-duty wheelchair (K0007), cushions (E2602, E2612), and seat frame (E2201). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery.
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 does now contain a valid proof of delivery for the supplies provided in this case. You sent a Delivery Ticket for these items. Therefore, we decided that the Plan has to pay for the extra heavy-duty wheelchair (K0007), cushions (E2602, E2612), and seat frame (E2201).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infection control supplies coded S8301 and the unlisted special service coded 99199 provided on November 9, 2020.
You asked the Plan to pay for the infection control supplies and the unlisted special service. 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. We find that CPT codes S8301 and 99199 are not supported in the medical record. Specifically, code S8301 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. Code 99199 should not be billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of the infection control supplies and the unlisted special service have not been met. Therefore, we decided that the Plan does not have to pay for the infection control supplies coded S8301 and the unlisted special service coded 99199 provided on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 19, 2020.

You asked the Plan to pay for the cardiovascular risk assessment 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 payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are not enough studies to show that the Coflex is safe and effective to treat back pain.
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 requested services. Our physician reviewer found the enrollee is being treated for spinal stenosis, lumbar region, with neurogenic claudication. He presents with complaints of continued lower lumbar pain. The lower back pain is constant, has been gradually worsening, and radiates to the bilateral lower extremities to the feet. There is associated leg pain, numbness, and weakness. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Coflex device at L4-5 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism purchased on October 15, 2020.

You asked the Plan to pay for a seat lift mechanism. You say that you were told by a representative of the Plan that the provider of the requested item was Medicare-certified. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism purchased on October 15, 2020.

Your complaint about receiving erroneous or incomplete information from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.