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

We decided that the Plan does not have to pre-approve the office visit and preventive evaluation to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit and preventive evaluation. You say that you went to this doctor for many years, and you trust this doctor. You say that he is clever, smart, serious and ladies should trust their OBGYN. The Plan denied your request. The Plan says in-network providers are available.

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 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. 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 the office visit and preventive evaluation to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records did not include a standard written order.

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. 

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary.

Our physician reviewer found that a standard written order was not provided in the records. 

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.

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 the lab services (87635) provided on July 27, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were not billed with the appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that HCPCS code U0002 and 87635 must have the modifier QW to be recognized as a test that can be performed in a facility having a CLIA certificate of waiver. 

We looked at the file and Medicare rules. The lab services were billed without the required -QW modifier. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (87635) provided on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.

You asked the Plan to pre-approve a knee orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a knee orthosis 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 a knee orthosis. Our reviewer says that the documentation does not support that the requested item is medically necessary. Our physician reviewer found there is no evidence of instability on a physical exam of the knees. The documentation does not reveal objective findings of laxity on a physical exam of the knees. There is no evidence of a recent surgery or injury to the knee. The enrollee is noted ambulatory but there is no evidence the patient requires the requested knee brace.

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cerebral perfusion analysis using CT with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time (CPT code 0042T), for the enrollee.

You asked the Plan to pre-approve the services. You say that the purpose of the CT perfusion scan is to identify whether the enrollee's left hemisphere is truly at risk of stroke. You state this type of scan will include an injection of acetazolamide which is a vasodilator which, if after administration, shows a worsened perfusion deficit on the enrollee's left hemisphere may prompt the necessary flow augmentation strategies (e.g. cerebral bypass) to prevent disability and mortality. The Plan denied your request. The Plan says there is no indication of current new/acute ischemic cerebrovascular accident (CVA) and no indication that endovascular intervention is planned.

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 physician reviewer found in this case the enrollee had a left middle cerebral artery stroke and left intracranial internal carotid artery occlusion. The enrollee has not had recent event. The record does not indicate that intervention is planned within 6-24 hours of any neurologic change from baseline. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve cerebral perfusion analysis using CT with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time (CPT code 0042T), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment of acute shoulder dislocation (23660) provided on October 1, 2020.

You asked the Plan to pay for the open treatment of acute shoulder dislocation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 open treatment of acute shoulder dislocation.

Our reviewer says that CPT code 23660 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a separate open treatment of acute shoulder dislocation was performed on October 21, 2020, therefore this service cannot be verified. 

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 open treatment of acute shoulder dislocation have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of acute shoulder dislocation (23660) provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on August 31, 2020, and September 30, 2020.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the services were processed correctly.

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 services are either not among those covered under this benefit or are subject to a cost share responsibility. The Plan only covers oral exams, cleanings, and x-rays. The records show that you were provided restorative services on September 30, 2020. Restorative services are not covered. The records also show that you were provided an oral exam, cleaning, bitewing x-rays, and full series x-rays on August 31, 2020.

You have been asked to pay a $10 copayment for the exam and cleanings, and a $20 copayment for each x-ray. Please note that this is less than the cost share outlined for these services in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for the dental services you received on August 31, 2020, and September 30, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.

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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level 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 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: Favorable

We decided that the Plan has to pre-approve custom fabricated wheelchair seat cushion (CPT code E2609) and solid seat support base (replaces sling seat) (CPT code E2231), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says that 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 based on the medical records provided there is documentation that the enrollee meets the requirements listed in the LCD: Wheelchair Seating for Medicare coverage. The provided records include a comprehensive written evaluation by a physical therapist which clearly explains why a prefabricated seating system is not sufficient to meet the enrollee's seating and positioning needs due to her kyphosis, weakness and pelvic obliquity with risk for skin breakdown and trial and failure of prefabricated options. 

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 been met. Therefore, we decided that the Plan has to pre-approve custom fabricated wheelchair seat cushion (CPT code E2609) and solid seat support base (replaces sling seat) (CPT code E2231), 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 open treatment of a scapular fracture (23585) provided on September 30, 2020.

You asked the Plan to pay for the open treatment of a scapular fracture. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 23585 is open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performed. 

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 open treatment of a scapular fracture. Our reviewer says that CPT code 23585 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a separate treatment of a glenoid fracture, therefore this service cannot be verified.

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 open treatment of a scapular fracture have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of a scapular fracture (23585) provided on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic, external, wearable defibrillator (K0606).

You asked the Plan to pre-approve the wearable defibrillator. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not billed separately when the enrollee is in inpatient care.

The Plan must follow Medicare rules. Medicare rules say that the DMEPOS benefit is meant only for items a beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institutional provider (e.g., hospital) is not defined as a beneficiary's home for DMEPOS, and so Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution. According to the claims history, the enrollee was in inpatient care. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wearable defibrillator have not been met. Therefore, we decided that the Plan does not have to pre-approve an automatic, external, wearable defibrillator (K0606).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's ongoing needs can be provided for at a lower level of care, such as a skilled nursing facility, on an intermittent basis at home with home health care, or in a long-term care setting.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for T10-11 and L4-L5 laminectomy. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (87635) provided on June 5, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were not billed with the appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that HCPCS code U0002 and 87635 must have the modifier QW to be recognized as a test that can be performed in a facility having a CLIA certificate of waiver. 

We looked at the file and Medicare rules. The lab services were billed without the required -QW modifier. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (87635) provided on June 5, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level 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 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 additional power wheelchair accessories (E2300, K0108, E2377, E2313).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the K0108 Light Kit and E2300 Seat Elevator do not serve a primary medical need and are therefore considered not medically necessary. The E2377 Expandable Controller, E2313 Expandable Controller Harness are requested to control power tilt and power elevating leg rests through the joystick. There are three power options are on the wheelchair (tilt, seat elevator and elevating leg rests), but only two (Power Tilt and Power Elevating Leg Rests)were deemed medically necessary. The documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc). You do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices, or an attendant control.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, K0108, E2377, E2313).