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

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on November 13, 2019.
You asked the Plan to pay for the compression stockings. You say that you have varicose veins and the compression stockings are needed to treat them. The Plan denied your request. The Plan says the compression stockings are examples of wound care items which are non-covered under the surgical dressing benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 that were issued on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
You asked the Plan to pre-approve Contour Next test strips. You say that The Plan denied your request. The Plan says that the information submitted doesn't meet medical necessity guidelines for coverage.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers. The items at issue are Contour Next test strips. Contour Next is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Febuxostat for the enrollee.
Benefits for this drug 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885) November 20, 2019.
You asked the Plan to pay for needle electromyography. You say that this code should be reconsidered for payment. The Plan denied your request. The Plan says the records do not contain documentation of this service.
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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). 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 needle electromyography. Our reviewer says that CPT 95885 is not supported by the submitted medical records. Our physician reviewer found the medical records provided do not include in the narrative of the operative note a description of a needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited as pedicle screw stimulations are not baseline nerve conduction studies, therefore this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885) November 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior lumbar fusion.You asked the Plan to pre-approve the posterior lumbar fusion. You say that you would like reconsideration because the member has had symptoms for a number of years and has tried physical therapy and steroid injections.The Plan denied your request. The Plan says the member has not tried physical therapy for at least 6 months and there is no documentation that physical therapy would be harmful.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 posterior lumbar fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent and adequate trial of physical therapy for back pain and there is no documented instability of the spine.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 posterior lumbar fusion have not been met.Therefore, we decided that the Plan does not have to pre-approve posterior lumbar fusion.
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 December 11, 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 by the records. 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 orthoses and sleeves have not been met. Documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.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 December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided on December 2, 2019 and January 9, 2019.
You asked the Plan to waive the copayments for X-rays. You say that you thought X-rays were included in post-operative follow-ups. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $35 copayment for X-rays. You received an X-ray on December 2, 2019. X-rays are not included in post-operative visits. Therefore, you are responsible to pay the $35 copayment. You received an X-ray on January 9, 2020. X-rays are not included in post-operative visits. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70 for X-rays. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for X-rays provided on December 2, 2019 and January 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on January 21, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you do not believe you should be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 forthe  emergency room visit provided on January 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing visits.
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration because these services are medically necessary. The Plan denied your request. The Plan says there is no need for continued home health nursing visits.
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 home health services. Our reviewer says that the request for ongoing home health nursing visits from March 9, 2020 through April 7, 2020 is not medically necessary. Our physician reviewer found the documentation does not reveal that you require the ongoing professional skills of a nurse for the management of your medical conditions which are stable. There is no evidence of IV medications, complex wound care, a new tracheostomy or new enteral feedings.
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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on November 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for ophthalmology services. You say that you went for a second opinion. The Plan denied your request. The Plan says there is no network deficiency for these services and alternate network providers were found.
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 ophthalmology services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on April 2, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on April 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee is not ready to go home alone at this time and is in therapy to continue strengthening. The appellant says that the enrollee will not be safe home alone and home services are limited due to COVID-19. The Plan denied your request. The Plan says the enrollee does not meet the reasonable and necessary criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no skilled nursing needs. The enrollee is not receiving IV medications or fluids. Routine monitoring of the enrollee's chronic medical conditions is being done. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments. The enrollee requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. While skilled therapy services are needed because the enrollee has not returned to his prior level of function, these needs are not required on a daily basis. The enrollee's care can be appropriately provided through home-based and outpatient services with intermittent scheduled services for lower body activities of daily living, if needed. If stair climbing is an issue, this would most appropriately occur on the actual stairs in the home setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IV iron infusion.
You asked the Plan to pre-approve IV iron infusion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that IV iron therapy is only covered for certain indications. 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 IV iron infusion. Our reviewer says that the documentation does not support that the requested iron therapy is medically reasonable or necessary. Our physician reviewer found a progress note dated March 11, 2020 states that the enrollee has been taking oral iron supplementation daily for two months with improvement of shortness of breath and fatigue. Labs revealed a hemoglobin level of 12.2 on March 11, 2020. The documentation does not indicate the enrollee has renal disease or is receiving dialysis. There is no documentation of iron studies. Medicare guidelines are not met and the request for intravenous iron infusions are determined not 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 IV iron infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve IV iron infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrocentesis (20610).You asked the Plan to pre-approve the arthrocentesis. You say that you would like reconsideration as this service is medically necessary.The Plan denied your request. The Plan says the member has not tried conservative care, there are no imaging studies and the x-ray is normal.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 arthrocentesis. Our reviewer says that there is insufficient documentation to determine the medical necessity of this request. Our physician reviewer found there is no current documentation of left shoulder subjective complaints, physical exam findings or imaging studies. There is no documentation of the response to the prior left subscapular injection to support the medical necessity of a repeat injection. There is no evidence of a recent trial or failure of conservative treatment for the left shoulder.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 arthrocentesis have not been met.Therefore, we decided that the Plan does not have to pre-approve arthrocentesis (20610).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan.
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 a PET scan. Our reviewer says that the documentation does not support that the requested PET scan is medically reasonable or necessary. Our physician reviewer found the enrollee elevated FLC (Free Light Chain Kappa Lambda) Ratio greater than 1,000, which is stable compared to 6 months ago, and mild hypercalcemia. The enrollee continues to do well symptomatically per provider. The enrollee has no M-spike on recent SPEP. A bone scan on September 26, 2019 showed no evidence of lytic or blastic lesions. The physician has a clinical concern about multiple myeloma or light chain disease. The enrollee declined bone marrow biopsy. PET imaging is not supported as a surveillance test for patients not receiving any active therapy for myeloma. This includes follow-up of equivocal FDG avidity on a previous PET study, which should be biopsied rather than followed with serial PET imaging. Therefore, the enrollee does not meet criteria for the requested PET scan. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee injection.
You asked the Plan to pre-approve a knee injection. The Plan denied your request. The Plan says the enrollee has not failed at least three months of conservative therapy.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation of the knee is only covered under certain medical indications. 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 knee injections. Our physician reviewer found that the enrollee has chronic left knee pain due to osteoarthritis and chondromalacia. He is taking Mobic for pain. He had an intra-articular steroid injection. Physical Therapy was ordered. The enrollee has not started a home exercise program. He has not been followed with conservative therapy for 3 months and has not had adequate trials of conservative therapy. Therefore, at this point the request is deemed 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 knee injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee injection.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health services
You asked the Plan to pre-approve home health services. The Plan denied your request.
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 home health services. Our physician reviewer found that you have a relevant past medical history that includes an intracerebral hemorrhage in November 2019 with left hemiparesis, diabetes, and hyperlipidemia. You are referenced as unable to use or move the left side of your body. You need assistance in activities of daily living, medication administration, range of motion, blood glucose monitoring, and as-needed insulin administration. You have urinary and bowel incontinence and require a two-person assist when transferring from bed to wheelchair. You are homebound due to the severity of your residual neurologic deficits. You have cognitive impairment and would not be expected to self-monitor your medical conditions, including monitoring your blood glucose or administer insulin. You also require assistance with personal activities of daily living. Therefore, the requested services are medically reasonable and 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 home health services have been met. Therefore, we decided that the Plan has to pre-approve home health services
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.