Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that Monovisc is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee arthritis confirmed on x-ray. A prior Monovisc injection on August 22, 2018 is documented as helping some. There is no documentation of significant improvement in knee pain and known improvement in functional capacity. Without this documentation, the repeat injection is 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Monovisc.
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 medically necessary. The Plan denied your request. The Plan says based on the documentation provided, medical necessity has not been established. Therefore, 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 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains within a predicted period. A SNF can safely and adequately address 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 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: 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 (L3020). You say that the enrollee needs custom orthoses for
proper offloading. The Plan denied your request. The Plan says this item is not a covered benefit without a leg
brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease and for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not wear a leg brace. Although orthotics may be appropriate for the
enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we
decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 3x per week for skilled nursing visits (G0299).
You asked the Plan to pre-approve the additional skilled nursing services. You say that the member needs skilled nursing visits to ensure they are taking their medication. The Plan denied your request. The Plan says the additional skilled nursing visits are not medically necessary.
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 the additional skilled nursing services. Our reviewer says that additional skilled nursing visits are not required to effectively provide treatment, care and/or services which are medically necessary for the member. Our physician reviewer found the records do not show a decline in function or medical status or care plan to warrant additional skilled nursing visits. 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 additional skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 3x per week for skilled nursing visits (G0299).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Inspire hypoglossal nerve stimulator.
You asked the Plan to pre-approve the Inspire device. You say that this is being denied due to a coding edit and
the code at issue is not the correct code for this system. You feel that the LCD being cited is not applicable to
the services at issue. The Plan denied your request. The Plan says this service is not covered by Medicare at
this time.
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve stimulator for Obstructive
Sleep Apnea is not covered as it is not found to be reasonable and necessary.
The code 0466T is the code used for the Inspire device. The argument that this code is not specific to this
device is not compelling. Based on this, we find that coverage for this device is correctly denied based on the
LCD text. Therefore, we decided that the Plan does not have to pre-approve the Inspire hypoglossal nerve
stimulator.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our reviewer says that the medication is medically necessary. Our physician reviewer found the enrollee has post-menopausal osteoporosis. The documentation does support that Prolia is medically reasonable and necessary for the enrollee. Prolia is approved by the FDA for treatment of post-menopausal osteoporosis. The documentation does support that Prolia is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on April 5, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on April 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle.
You asked the Plan to pre-approve a power operated vehicle (K0806). You say that you want a power scooter for going to the store and things like that. The Plan denied your request. The Plan says the medical record shows you are ambulatory in your home without a cane or walker and this POV is not covered by Medicare.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, or that your condition cannot be improved by a walker, cane or manual wheelchair. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers power mobility devices for use only outside the home. Medicare rules for coverage of this POV have not been met, therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP backup battery.You asked the Plan to pre-approve a CPAP backup battery. You say that there are electrical problems where you live and lack of use of your CPAP affects your health.The Plan denied your request. The Plan says Medicare will not pay separately or make any additional payment for backup equipment and the supplier should deal with equipment interruption.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME.Medicare does not pay for precautionary equipment. Therefore, we decided that the Plan does not have to pre-approve a CPAP backup battery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing performed on July 12, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support the billing of code G0483.
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 G0483 is drug tests, definitive; qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug classes, including metabolites if performed. We asked our 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 drug test. Our reviewer says that the billed procedure code G0483 does not meet the Medicare criteria for payment. Our physician reviewer found the record does not contain evidence that definitive drug testing was performed on 22 or more drug classes, therefore code G0483 is not supported for payment. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing performed on July 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve atorvastatin 40mg tablets.You asked the Plan to pre-approve the atorvastatin tablets. You say that this medication is medically necessary.The Plan denied your request. The Plan says this oral drug cannot be covered by Medicare Part B. Part D coverage must be requested.The Plan must follow Medicare rules.The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve atorvastatin 40mg tablets.Benefits for the atorvastatin tablets may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hot packs and shoulder pulley system.
You asked the Plan to pre-approve hot packs and shoulder pulley system. You say that you need hot packs and shoulder pulley system to treat your shoulder pain. The Plan denied your request. The Plan says hot packs are a convenience item and a pulley system is exercise equipment, both not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME. Therefore, we decided that the Plan does not have to pre-approve hot packs and shoulder pulley system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora jaw bone graft (21215) provided on May 1, 2019.You asked the Plan to pay fora jaw bone graft. You say that this code is supported.The Plan denied your request. The Plan says this is not supported by the medical records submitted.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 21215 is graft, bone; mandible (includes obtaining graft). 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 a jaw bone graft. Our reviewer says that the medical records provided do not include documentation to corroborate that a graft bone; mandible (includes obtaining graft) was performed on May 1, 2019. Our physician reviewer found according to the National Correct Coding Initiative Policy Manual regarding CPT code 21215, the following description should be present in the operative note, "the physician reconstructs the mandible with a bonegraft to correct defects due to injury, infection, or tumor resection. The procedure may also be performed to augment atrophic or thin mandibles, or to aid in healing fractures. The physician harvests bone from another site on the patient's body, most commonly the rib, hip, or skull, and repairs the surgically created wound. The physician makes facial skin incisions to expose the mandible and place the graft from the donor site. Occasionally, intraoral incisions are used. The graft is held firmly positioned with wires, plates, or screws. The incisions are sutured with a layered closure. Any bone graft harvest is not reported separately. For harvest of graft by another physician, report the applicable bone graft code. For interdental wiring, see 21497. For application, including removal of an interdental fixation device for conditions other than fracture or dislocation, see 21110. Because this procedure may be performed for cosmetic purposes, verify with the insurance carrier for coverage. This description was not documented in the medical records submitted." This description was not included in the procedure documentation, therefore, it is inappropriate to bill CPT code 21215 for reimbursement consideration.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 jaw bone graft have not been met.Therefore, we decided that the Plan does not have to pay fora jaw bone graft (21215) provided on May 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot, insert, removable, molded to patient model (CPT
Code L3000).
You asked the Plan to pre-approve foot orthotics. You say that you fractured your foot three months ago and it
has not healed although you were provided a boot as well as physical therapy. You state you are diabetic and
need the shoe insert to assist with healing your fracture. The Plan denied your request. The Plan says since you
do not have severe diabetic foot disease, Medicare does not cover orthotics even if they are medically
necessary to treat your foot problem.
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.
Orthotics or shoe inserts are only covered if you have diabetes with nerve damage to your feet and you have or
have had calluses or ulcers. Your appeal tells us that you are having foot pain and you need orthotics. You have
diabetes, but your podiatrist told us you do not have calluses or ulcers. We agree that orthotics may help you
but Medicare only covers foot orthotics if it is part of shoes provided for severe diabetic foot disease or if it is
part of a brace. Therefore, we decided that the Plan does not have to pre-approve foot, insert, removable,
molded to patient model (CPT Code L3000).
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. The Plan denied your request. The Plan says the enrollee's needs can be safely met in the current hospital 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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for perforated diverticulitis. The enrollee's post-operative course was complicated by wound dehiscence. The enrollee is receiving wound care, antibiotics and enteral nutrition. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for rehabilitation services provided from January 5, 2019 through March 27, 2019.
You asked the Plan to waive the copayment for rehabilitation services. You say that this was for general care and your husband's policy doesn't allow balance billing and he got a bill for $950. The Plan denied your request. The Plan says inpatient hospital care has a $100 copayment per day for days 1-10. The Plan also says that starting day 11 and beyond there is a $0 copayment per day.
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 enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment per day for days 1-10 for inpatient hospital care. The enrollee has been asked to pay a $100 copayment per day for days 1-10 for rehabilitation services. This service falls within the inpatient hospital care benefit category. For dates of service January 5, 2019 through January 15, 2019 there is a $100 copayment per day for 1-10 days ($100 x 10 = $1,000). The enrollee is being asked to pay $950. This is less than the normal amount for inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for rehabilitation services provided from January 5, 2019 through March 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy (PT) and occupational therapy (OT) (97110,
97116, 97150, 97161, 97165, 97530, 97535) provided on July 17, 2019 to July 23, 2019 by the out of network
provider.
You asked the Plan to pay for PT and OT. You say that you are appealing the claim for denial as you rendered
services to the member on July 27, 2019. The Plan denied your request. The Plan says the services were not
authorized because the facility is a non-network provider who does not work with the member's
health plan, and the member was referred by a physician, who also does not work with the member's plan.
The member's primary care physician did not refer for services. The health plan requires utilization of network
providers when possible and available and requires authorization for certain services. No medical necessity for
an out-of-network provider, such as an urgent or emergency situation, had been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physical therapy (PT) and occupational therapy
(OT) (97110, 97116, 97150, 97161, 97165, 97530, 97535) provided on July 17, 2019 to July 23, 2019 by the out of
network provider.