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

We decided that the Plan has to pre-approve a special power wheelchair

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker, cane or manual wheelchair, and the patient is 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 wheelchair. Our reviewer says that the requested wheelchair is medically reasonable or necessary. Our physician reviewer found the enrollee is unable to ambulate household distances. The enrollee has comorbid upper extremity and lower extremity impairment and super morbid obesity. The enrollee would not be expected to use a properly-fitted standard mobility aide to overcome her MRADL deficits. The enrollee had previously used a power wheelchair, and would be expected to safely operate the new one. The information confirms that the enrollee's mobility related activities of daily living cannot be met through the use of standard mobility aides. She has right lower extremity lymphedema which supports providing power elevating her legs and a power tilt seating system. She has neurologic disorders of polyneuropathy likely attributed to diabetes and left lower extremity sciatica. She is a long-term power wheelchair user. The Group 3 power wheelchair being requested is medically necessary for the treatment of this enrollee's condition.

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 wheelchair have been met. Therefore, we decided that the Plan has to pre-approve a special power wheelchair 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee August 2, 2018.
You asked the Plan to pay for the intermittent compression device. 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.
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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain valid proof of delivery for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to corroborate with the proof of delivery. Therefore, the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee August 2, 2018.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay foranesthesia services (CPT 99100) provided to the enrollee on June 21, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysthatCPT 99100 is always bundled per CMS guidelines, and remains denied.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 99100 is "Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia 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 the services. Our reviewers says that the services at issue in this were coded correctly. Our physician reviewer found qualifying circumstance CPT code 99100 should be reported, when supported, as a modifier to a base anesthesia code. In this case, the enrollee was over 70 years old, so reporting the modifier is supported. The modifier (99100) may thereby affect the value of the base code (00811).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 been met.Therefore, we decided that the Planhas to pay foranesthesia services (CPT 99100) provided to the enrollee on June 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the total knee placement and the physical therapy evaluation provided from November 15, 2019 to November 16, 2019.
You asked the Plan to waive the cost share for the total knee replacement and the physical therapy evaluation. You say that you were not considered an outpatient because you spent the night in the recovery room. 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 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a total of $2,638.54 for the total knee replacement and the physical therapy evaluation. The total knee replacement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The physical therapy evaluation falls within the "Outpatient Rehabilitation Services" benefit category. The record shows the total knee replacement is considered an outpatient surgery. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance/Copayment
Member Liability
November 15, 2019-November 16, 2019
Total knee replacement
$12,992.72
20%
$2,598.54
November 15, 2019-November 16, 2019
Physical therapy evaluation
$95.45
$40.00
$40.00
Total
$2,638.54
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 cost share for the total knee placement and physical therapy evaluation provided from November 15, 2019 to November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the
out of network (OON) provider on April 1, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of
network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not
have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider on
April 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided from January 17, 2020 to January 21, 2020. You asked the Plan to pay for home infusion therapy. You say that this should be processed as in-network. The Plan denied your request. The Plan says this code is not valid. 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 find that CPT code S9502 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) provided from January 17, 2020 to January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the electrocardiographic monitoring provided on December 13, 2019.
You asked the Plan to waive the coinsurance for the electrocardiographic monitoring. You say that the hospital should have sent the claim to an in-network provider and you do not feel that you should have to pay the $8.00 charge. The Plan denied your request. The Plan says the cost share was initially incorrectly calculated and has been adjusted to 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 20% of the cost for Medicare-covered diagnostic procedures and tests. You have been asked to pay $7.87 which is 20% of the allowed amount for the electrocardiographic monitoring. The allowed amount is $39.34. ($39.34 x 20% = $7.87). The electrocardiographic monitoring falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows this service was applied to the in-network benefit.
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 coinsurance for the electrocardiographic monitoring provided on December 13, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a full night titration study.
You asked the Plan to pre-approve a full night titration study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sleep studies are 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 full night titration study. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with obstructive sleep apnea (REI of 40 on a home sleep test) and has been referred to the sleep center for an attended titration study. Medicare has established that attended sleep testing is covered for obstructive sleep apnea. According to the applicable LCD, "The appropriate level for CPAP is best determined during a CPAP titration PSG. A titration PSG provides useful information on the appropriate level of CPAP during one single night in a dedicated environment." This language reflects that the requested sleep study is covered by Medicare. Therefore, the requested study would meet Medicare criteria for coverage and it would otherwise be considered to be reasonable and necessary for the enrollee to have such a test/procedure.
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 full night titration study have been met. Therefore, we decided that the Plan has to pre-approve a full night titration study.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional visits for skilled nursing home care and six additional visits for home physical therapy services You asked the Plan to pre-approve the additional visits. You say that none of the doctors want you to come in because of your immune problems.The Plan denied your request. The Plan says these additional visits are not medically reasonable or necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says that the requested additional visits is not medically reasonable or necessary. Our physician reviewer found the records do not show that additional skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you beyond what was approved by the health plan. There are no complex wounds, IV medications, new enteral feedings or other skilled nursing need. You do not require a frequency of over once a week INR results. You should be instructed on disease management at this point and your pain management does not require ongoing nursing visits. Your functional status does not require ongoing skilled therapy services to effectively provide treatment, care, and/or services which are medically necessary for you beyond what was approved by the health plan. You were instructed in a home exercise program and your remaining deficits do not require ongoing skilled PT.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve five additional visits for skilled nursing home care and six additional visits for home physical therapy services
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for shortness of breath. The enrollee is not intubated/ventilated. 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, incontinence wipes and washcloths (E1399).You asked the Plan to pre-approve incontinence supplies. You say that you have frequent feces related accidents at night and you have been fortunate enough to receive incontinence supplies but you were denied the wipes and you usually receive 2 packs of 100 a month.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, incontinence wipes and washcloths (E1399).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe sleep study (95811) provided on December 12, 2019 by anout of network (OON) provider.You asked the Plan to pay foran OON sleep study. You say that you were not aware this was the enrollee's primary insurance.The Plan denied your request. The Plan says these services were not authorized.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 forthe sleep study (95811) provided on December 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (CPT E0118).
You asked the Plan to pre-approve the crutch substitute. You say that you cannot use crutches because you do not have strength in your arms and hands. You say that your other foot has arthritis in the large toe, and that toe does not bend. You say that putting all pressure on this toe creates pain. You say that you don't have the equilibrium for the crutches. You say that you have scoliosis, so one hip is higher than the other, which further throws off your equilibrium. The Plan denied your request. The Plan says the device being requested is not covered by Medicare or under your health plan contract.
The Plan must follow Medicare rules. Medicare rules say that items and 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. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (CPT E0118).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nulojix (belatacept) (J0485) for home infusion.You asked the Plan to pre-approve Nulojix for home infusion. You say that the enrollee needs this drug administered at home to keep him from rejecting his kidney transplant.The Plan denied your request. The Plan says this drug is not covered in the home.The Plan must follow Medicare rules. Medicare rules say that belatacept (J0485) is not proven to be safe when administered in the home setting and therefore will be denied as not medically necessary when provided in that setting.We looked at the file and Medicare rules. The records show that this is being requested for home administration, which is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix for home infusion have not been met.Therefore, we decided that the Plan does not have to pre-approve Nulojix (belatacept) (J0485) for home infusion.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an electroencephalogram during surgery (95955) provided on May 10, 2019.
You asked the Plan to pay for the electroencephalogram. You say that you would like reconsideration because this code is not subject to bundling rules. The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.
The Plan must follow Medicare rules. Medicare rules say that all line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI procedure-to-procedure (PTP) edits. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram have been met. Specifically, the codes at issue were billed by separate providers with different NPI. These codes are not subject to NCCI PTP edits. Therefore, we decided that the Plan has to pay for an electroencephalogram during surgery (95955) provided on May 10, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on January 3, 2020.You asked the Plan to pay for the periapical x-ray. You say that you were experiencing pain in your tooth. You say that you wanted it checked out before it turned into something potentially worse.The Plan denied your request. The Plan says periapical x-rays are not listed as a covered service.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 periapical x-ray is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on January 3, 2020.