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

We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
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. 
 
We looked at the file and Medicare rules. The file does not indicate you are completely unable to stand up from a regular chair. Based on this information, we decided that Medicare rules for coverage of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plan does not have to pre-approve inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient behavioral health admission. You say that please reconsider prior authorization. You received a denial based on time frame compliance. The enrollee meets criteria for inpatient hospitalization and benefit from services. The Plan denied your request. The Plan says timely notification to the health plan for inpatient care is required. The notification was not timely and medical necessity for inpatient behavioral admission was not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  
 
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 inpatient behavioral health admission. Our reviewer says that this enrollee does not meet the criteria for an inpatient behavioral health admission. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not a danger to self or others and was not showing any delusions or auditory/visual hallucinations while not showing any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she was not a danger to self or others.  This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that this provider is closest to your house. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The 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 a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable


 We decided that the Plan does not have to pay for drug testing provided on September 6, 2019. 
 
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records for the billed test. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab code billed. 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 provided on September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra Pen 30 mg/ml (J0517). 
 
You asked the Plan to pre-approve Fasenra Pen 30 mg/ml. You say that the requested medication is necessary. The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Fasenra Pen 30 mg/ml (J0517).  
 
Benefits for Fasenra Pen 30 mg/ml 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the shoulder (73030) provided October 7, 2019.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary and the claim
should be paid. The Plan denied your request. The Plan says the auto insurer has already paid the allowable
amount.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has received an
Explanation of Benefits from the primary insurer showing that the allowed amount has been paid. As the
secondary insurer, the Plan cannot be held responsible for the x-ray unless the primary insurer has denied the
claim for these services. Therefore, we decided that the Plan does not have to pay for an x-ray of the shoulder
(73030) provided October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics and transit kit. 
 
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377) and transit kit (E0108). You say that you need the upgraded electronics and transit kit. Plan denied your request. The Plan says there is not a medical need to control the power options through the joystick and the transit kit does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The transit kit 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 and is used outside the home. The documentation indicates the enrollee has sufficient functional ability in the upper extremities to control the power features through their own individual switches. Therefore, we decided that the Plan does not have to pre-approve power wheelchair upgraded electronics and transit kit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography Angiography (CTA) of the chest (71275).
You asked the Plan to pre-approve the CTA. You say that the requested test is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CTA. Our reviewer says that the CTA of the chest is not medically necessary. Our physician reviewer found nuclear medicine stress test and echocardiogram were performed in 2019 as part of evaluation and were negative. The requested CT of coronary arteries is 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 the CTA have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography Angiography (CTA) of the chest (71275).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a crutch substitute (E0118 and A9901) provided on August 8, 2018 through October 22, 2018.
You asked the Plan to pay for the crutch substitute. You say that you would like reconsideration because you were told this item would be covered. The Plan denied your request. The Plan says this item is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the crutch substitute have not been met. Per the Durable Medical Equipment MAC, there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products. Therefore, we decided that the Plan does not have to pay for a crutch substitute (E0118 and A9901) provided on August 8, 2018 through October 22, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve core buildup for teeth 2, 3, 5, 7, 8 (D2950).
You asked the Plan to pre-approve the dental services. You say that you are requesting an appeal to the denied services. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup for teeth 2, 3, 5, 7, 8 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that because of your medical condition you need a wig. The Plan denied your request. The Plan says a wig does not serve a primarily medical purpose. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on August 21, 2019. 
 
You asked the Plan to pay for the drug testing. You say that the services are considered an extension of the enrollee's office visit. The Plan denied your request. The Plan says the medical records do not include definitive lab results for 8-14 drug classes. 
 
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 G0481 is definitive drug testing of 8-14 drug classes.  We find that CPT code G0481 is not supported in the medical record. There is no evidence in the medical records that shows the test was individualized to identify specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair batteries and modifications. 
 
You asked the Plan to pre-approve the power wheelchair batteries and modifications. You say that the wheelchair batteries are no longer covered under warranty and the other items are modifications. The Plan denied your request. The Plan says the enrollee resides in a SNF and therefore wheelchairs, batteries and accessories are not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home.  
 
Records show that the power wheelchair batteries and modifications are being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair batteries and modifications.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit for a new patient (99342) provided on August 1, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the member's condition. 
 
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 99342 is home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.  
 
We find that CPT code 99342 is not supported in the record. Specifically, the record indicates that this member has been seen by this physician group within the last 3 years. The record indicates that this is not a new patient, therefore billing CPT code 99342 is not appropriate. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit for a new patient (99342) provided on August 1, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of the implant body, tooth 21 (D6010) and abutment supported porcelain fused to metal crown, tooth 21 (D6059).
You asked the Plan to pre-approve the dental services. You say that the implant and implant crown #21 is needed to restore missing tooth #21 and chewing function to quad 3. The Plan denied your request. The Plan says these services are not covered under the plan benefits.
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. The health plan contract specifically says that any services not listed is not covered by the plan. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of the implant body, tooth 21 (D6010) and abutment supported porcelain fused to metal crown, tooth 21 (D6059).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP back up battery.
You asked the Plan to pre-approve a CPAP back up battery. The Plan denied your request. The Plan says that alternative power sources are not considered by Medicare as durable medical equipment.
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. Therefore, we decided that the Plan does not have to pre-approve a CPAP back up battery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat
exchanger provided on February 18, 2020.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to
the enrollee during a surgery and should be covered. The Plan denied your request. The Plan says this claim
cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers.
This equipment was used during a surgical procedure by the facility. Payment for this service would have been
included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital.
Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator
or heat exchanger provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature or attendant control.
You asked the Plan to pre-approve a power seat elevation feature (E2300) and attendant control (E2331). You say that you need a Group 3 power wheelchair, accessories, power seat elevation feature, and attendant control. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan and there is no documentation of your inability to operate the power wheelchair yourself.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The power seat elevation feature does not serve a purpose that is primarily medical in nature. This feature is not
covered by Medicare. The record shows you are able to safely operate a power wheelchair in the home. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature or attendant control.
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 the services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient 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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
complications related to his multiple myeloma. The enrollee was transiently intubated/ventilated, but has since
been extubated and is no longer on a ventilator. There is no evidence that the enrollee requires services that are
not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care (LTC) 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 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.