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

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the physician and the enrollee state that if the second ventilator is not received then there's a possibility of mortality. The Plan denied your request. The Plan says Medicare does not cover a second, back up ventilator.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home ventilator have not been met. Review of the information shows that the enrollee has lung disease and a second ventilator is being requested as a backup. However,
Medicare does not cover a second, back up ventilator. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (CPT code E0277), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the enrollee currently has no evidence of a pressure/decubitus ulcer, this is due to the great efforts the enrollee's caretakers go through to prevent this condition. The Plan denied your request. The Plan says the Medicare rules have not been met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer found there is no documentation that meets the requirements listed in the LCD: Pressure Reducing Support Surfaces - Group 2 (L33642) for Medicare coverage of the requested powered pressure-reducing air mattress. The provided records do not document that the enrollee has had multiple stage 2 pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the enrollee has been on a comprehensive ulcer treatment program or has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past sixty (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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (CPT code E0277), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this was prescribed for a medical need. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this request is medically necessary for your pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 25, 2021, to
February 4, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you have attached the relevant medical
record for review. You request for reconsideration of the previous decision and provide coverage for the
services denied. The Plan denied your request. The Plan says that the services could have been provided at
observation level of care.
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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the emergency department on January 25, 2021, with right lower
quadrant pain, weakness. A surgical consultation was obtained and recommended an aggressive bowel
regimen. His ambulation was impaired, and he underwent MRI studies of the brain, cervical and lumbar spine.
MRI of the brain demonstrated a subacute infarct right cerebellum with hemorrhagic conversion. He had
bradycardia and was evaluated by Cardiology and was started on Amlodipine for blood pressure control. He
participated in physical therapy and was stable for discharge on February 5, 2021. The record does show that at
the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital
care (including earlier ED and/or observation care) would span two 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from January 25, 2021, to February 4, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) (CPT code 78708).
You asked the Plan to pre-approve the imaging. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules 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 the imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found guidelines require a finding of hydronephrosis and glomerular filtration rate (GFR) greater than 15 mL/min/1.73 m2. However, the lab values showing you with a GFR of greater than 15 was not provided for review to meet the above criteria. Therefore, without this supportive information, this request will be considered not medically necessary based on the provided documentation.
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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) (CPT code 78708).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on April 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service and is not separately 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, we have confirmed that code 70544 has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70544) provided on April 13, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve Proton Beam Therapy: Guidance for localization of target delivery of radiation treatment (CPT code 77387), stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy (CPT code G6002) and proton treatment delivery, complex (CPT code 77525), for the enrollee.

You asked the Plan to pre-approve the services. You say that this enrollee's particularly aggressive re-occurring cancer, proton beam therapy is the best treatment. The Plan denied your request. The Plan says that there is no current research showing that the enrollee's type of cancer responds better to the requested type of treatment than the type of treatment that can be approved.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the records demonstrate, that this enrollee's clinical situation is exceptional given the plan to offer a second course of radiation to the same site- with critical organs (primarily normal bowel) able to better spared with proton therapy. Reirradiation would meet the criteria. Therefore, the decision should be favorable as the treatment of this enrollee with proton therapy would be furnished in accordance with accepted standards of 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 services have been met. Therefore, we decided that the Plan has to pre-approve Proton Beam Therapy: Guidance for localization of target delivery of radiation treatment (CPT code 77387), stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy (CPT code G6002) and proton treatment delivery, complex (CPT code 77525), for the enrollee.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 24, 2020.
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 codes 11044 and 25350 are 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 is debridement, bone (includes epidermis, dermis,
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. The definition of code 25350 is
osteotomy, radius; distal third.
We find that CPT codes 11044 and 25350 are not supported in the medical record. Specifically, there is no
documentation of bone debridement for the first 20 sq cm or less to support code 10044. There is no
documentation of an osteotomy of the distal third of the radius to support code 25350. 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 surgical services rendered on September 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003 x 3) provided from
September 8, 2020, to September 21, 2020.

You asked the Plan to pay for the laboratory services. You say that the enrollee was no longer enrolled in
hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim would be
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of
election until the last day of the month in which hospice is revoked.

The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services
and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on September 6, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the coronavirus
testing (U0003 x 3) provided from September 8, 2020, to September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychotherapy services you received from
February 4, 2021, to May 19, 2021.
You asked the Plan to waive the copayments for the psychotherapy services. You say that you were told there
was no copayment for individual therapy. The Plan denied your request. The Plan says you were charged these
copayments 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 $40
copayment for each individual or group therapy visit.
You have been asked to pay a $40 copayment for each of the psychotherapy services. 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 copayments for psychotherapy services you received from February 4, 2021, to May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter implementation of wireless pulmonary
artery pressure sensor (CardioMEMS) (CPT code 33289) for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee's symptoms are worse, and this device
will allow you to better monitor and manage those symptoms that lead to repeat heart failure hospitalizations.
The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s)
is helpful for treatment of the enrollee's health problem.
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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that the enrollee was admitted to the hospital in December 2020 for a
NYHA class III exacerbation. The enrollee has a body mass index (BMI) of 40. The chest circumference is not
reported. Records from more recent dates of service that address the requested service are not provided. The
elements of the coverage criteria 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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve transcatheter implementation of wireless pulmonary artery pressure sensor (CardioMEMS)
(CPT code 33289) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, lower extremity; without contrast material (CPT
code 73700).

You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your
request. The Plan says they did not receive physical exam results that show a reason this study is needed. The
Plan states your records did not include a detailed history that shows this study is needed. The Plan states they
need to see results of an x-ray taken after your symptoms started or changed that failed to provide all of the
details needed.

The Plan must follow Medicare rules. 

We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the CT scan have not been met. Review of the file does not show
that medical records were provided. Therefore, without this information we cannot make a determination if the
CT scan meets Medicare criteria. Therefore, we decided that the Plan does not have to pre-approve CT, lower
extremity; without contrast material (CPT code 73700).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete intraoral x-rays rendered on June 2, 2021.

You asked the Plan to pay for these services. You say that the x-rays were needed to identify hidden decay. The
Plan denied your request. The Plan says the services are not a covered benefit.

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 pay for the
complete intraoral x-rays rendered on June 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy (45380) and anesthesia for a lower intestinal endoscopic procedure (00811) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a colonoscopy and anesthesia. You say that you were approved for a visit with this provider, and you do not understand why the Plan is now denying services with this provider. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The records show that you were approved for one (1) office visit with the requested out-of-network provider. The records also show that you had the approved office visit on May 25, 2021. 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 records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy (45380) and anesthesia for a lower intestinal endoscopic procedure (00811) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental for the treatment of back pain. More research is needed to show safety and efficacy of the procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for intravenous infusion services (CPT code(s): 96361, 96365, Q9967, 96375) provided to the enrollee from December 28, 2020, through December 29, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that the services are not supported by the records.
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 services. Our reviewer found the documentation received was reviewed and it was determined that the records did support the services provided on December 28, 2020, to December 29, 2020. 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 services have been met. Therefore, we decided that the Plan has to pay for intravenous infusion services (CPT code(s): 96361, 96365, Q9967, 96375) provided to the enrollee from December 28, 2020, through December 29, 2020.
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.