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

We decided that the Plan does not have to pre-approve the CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device.. You say that the service is necessary. The Plan
denied your request. The Plan says the service is not 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 CardioMEMS device. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs
device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission
compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial
calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time
according to leading authorities and not recommended in current guidelines for the treatment of heart failure.
Medicare coverage criteria are not met, since the device should still be considered experimental or
investigational.
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 CardioMEMS device. have not been met. Therefore, we decided that the
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20611) provided on May 9, 2020.
You asked the Plan to pay for the arthrocentesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. 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 arthrocentesis. Our reviewer says that CPT code 20611 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted did not include permanent recording and reporting.
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 arthrocentesis have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis (20611) provided on May 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Power Operated Vehicle (POV)You asked the Plan to pre-approvea POV. You say that you require the device. The Plan denied your request. The Plan says were evaluated by Physical Therapy and are noted to be appropriately ambulatory in your entry level apartment.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 shows thatyou do not have a mobility deficit that impairs your participation in MRADLs. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Power Operated Vehicle (POV)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 requestedIRF 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. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is no documentation that you require the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more appropriate in this case.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-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye refraction (92015) provided on July 23, 2020.
You asked the Plan to pay for the eye refraction. You say that the service should be covered. The Plan denied
your request. The Plan says that Medicare only covers ophthalmological services which include medical
examination and evaluation, with initiation or continuation of diagnostic and treatment program.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine eye exam a year.
We looked at the file and the Plan's rules. The record does not show that you have previously exhausted your
one supplemental routine eye exam for the 2020 calendar year. Based on this information, we decided that the
Plan's rules for coverage of eye refraction have been met. Therefore, we decided that the Plan has to pay for the
eye refraction (92015) provided on July 23, 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Prolia 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on February
25, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not show evidence of recent injury, surgery or joint laxity with
knee instability.
The Plan must follow Medicare rules. Medicare rules say that for a knee orthosis to be covered there must be
documentation of objective joint laxity, instability, recent injury or surgery to the knee.
The documentation does not show any of the covered indications for the knee orthosis. Therefore, we decided
that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursementfor the seat lift mechanism (E0627) purchased on February 6, 2020.You asked the Plan to issue reimbursementfor this item. You say that you are requesting a reconsideration of the Plan's denial for paymentas a seat lift mechanism is medically necessary.The Plan denied your request. The Plan says there has been insufficient documentation of medical necessity provided. Additionally, the item was purchased from a non-Medicare provider.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.Additionally, no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met.Specifically, there has been no medical documentation provided to substantiatethat you meet the Medicare criteria for coverageofa seat lift mechanism. Additionally, the seat lift mechanismwas purchased from a provider that does not participate in the Medicare program. Therefore, we decided that the Plan does not have to issue reimbursementfor the seat lift mechanism (E0627) purchased on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition (HCPCS B4197) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Healthcare Common Procedural Coding System (HCPCS) code B4197 (7 Units) remains not supported, as the submitted medical recodrs do not support the units 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 HCPCS code B4197 is "Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein.

"We find that HCPCS code B4197 is not supported in the medical record. Specifically, the records do not support the amount of units billed on the claim. 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 pay for parenteral nutrition (HCPCS B4197) provided to the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for an electrocardiogram (93010) provided.

You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this service is a bundled service with the emergency department visit (99285) that was billed on the same date of service.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any evidence that the primary code was processed and paid. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay for an electrocardiogram (93010) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forDexcom G6 Transmitter continuous glucose monitor (CGM)You asked the Planto pay forthe CGM. You say that you would like to use the Dexcom CGM.The Plan denied your request. The Plan says you have not given sufficient information on why you cannot use the plan preferred FreeStyle Libre CGM.The Plan must follow Medicare rules. Medicare rules say that a plan may specify what DME providers certain DME can be covered. Our reviewer did not see certain information that is required in order to approve the non-preferred requested monitor. We looked at the file and Medicare rules. The preferred monitor is the Freestyle Libre Flash Line. We based this decision on your health plan's step therapy criteria named Non-preferred Continuous Glucose Monitor (CGM). Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plan does not have to pay forDexcom G6 Transmitter continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on June 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 the rest home visit services provided on June 19, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora digital analysis of electroencephalogram provided to the enrollee on April 28, 2020.You asked the Plan to pay forthe services. You say that the Plan denied your request. The Plan says this code is not separately payable as 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 95957 is "digital analysis of electroencephalogram."We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found per the National Correct Coding Initiative edits;CPT 95957 is not payable when with billed with CPT 95955. This is a misuse of a column 2 code with a column 1 code and a modifier is not allowed to unbundle these 2 services.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 not been met.Therefore, we decided that the Plan does not have to pay fora digital analysis of electroencephalogram provided to the enrollee on April 28, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe occupational therapy service provided on June 23, 2020.You asked the Plan to waive the copayment foroccupational therapy service. You say that this appointment was cancelled by the therapist.The Plan denied your request. The Plan says the medical records received show you were seen for therapy on June 23, 2020.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 $20 copayment for outpatient therapy. You have been asked to pay a $20 copayment for the physical therapy service.Theoccupationaltherapy service falls within the outpatient therapybenefit 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.The record shows you had an occupational therapyevaluationon June 23, 2020. Therefore, we decided that the Plan does not have to waive the copayment forthe occupational therapy service provided on June 23, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the enrollee on April 6, 2020.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery and relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. Therefore the billed code cannotbe verified.  The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the enrollee on April 6, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing (SN) services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not have complex wound care or other ongoing SNF level SN need. The patient's high functional level does not require skilledtherapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 
SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a SNF 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea rollator for the enrollee.You asked the Planto pre-approvethe rollator. You say that this is medically necessary.The Plandenied your request. The Plansayssimilar equipment -walker and wheelchair -is already owned.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 rollator. Our reviewer says that the requested rollator is not considered medically reasonable and necessary in this case. Our physician reviewer found it is not clear that the enrollee's mobility deficit impairs ability to perform MRADLs currently in the home. The enrollee has a standard walker, and there is no indication that the enrollee is unable to use this walker effectively. Without evidence of inability to use the current walker in the home the documentation indicates that a rollator walker would exceed his medical need and is not medically necessary. There is also no evidence of a trial with a rollator walker that indicates the enrollee's functional deficit can be safely resolved with the requested rollator.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 rollator have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea rollator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cardiovascular risk assessment testing provided on May 6, 2020.You asked the Plan to pay forthe cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The cardiovascular risk assessment testing at issue in this appeal, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe cardiovascular risk assessment testing provided on May 6, 2020