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

We decided that the Plan does not have to pay for podiatry services provided on September 17, 2019 by out of network provider.
You asked the Plan to pay for podiatry services. You say that these services were medically necessary. You say that these services are provided at an assisted living facility. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the assisted living facility is also out-of-network.
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 podiatry services provided on September 17, 2019 by out of network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (49411, 49412, 77387, 77263, 77417, 77280, 77427, 77290, 77525, 77295, G6002, 77300, 77301, 77334, 77336, and 77338).
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy 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 proton beam radiation therapy. Our reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician reviewer found the most recent NCCN guidelines for colorectal cancer (v1.2020) discuss "conformal radiotherapy" and SBRT for liver metastases, and explicitly describe the use of 3D conformal radiation therapy, IMRT or SBRT, but not proton therapy. Proton therapy can be considered medically necessary when justified with quantitative dosimetric information that shows a clinically meaningful reduction in radiation dose exposure of normal tissues. In order for toxicity risks to be reduced, there should be a clinically significant reduction in dose to critical structures, with an evidence basis of benefit with dose reduction. Recent systematic QUANTEC reviews provide such guidelines that help clinicians evaluate the acceptability of a radiation plan. This enrollee is to undergo radiation to 2 sites (with a history of multiple liver metastases) and multiple prior therapies including SBRT, bland embolization, radiodembolizarion. Two issues remain unclear in this case. Why is radiotherapy being offered to this enrollee who last had an embolization procedure in Oct 2019, with January 2020 imaging showing no progression of disease? Why would more standard approaches of radiotherapy such as SBRT, or (if choosing to use a more protracted course of radiation) IMRT/IGRT with arcing beams that can minimize dose spill into the liver and surrounding tissue. For this case, no dosimetric parameters are provided to establish the necessity of proton therapy for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (49411, 49412, 77387, 77263, 77417, 77280, 77427, 77290, 77525, 77295, G6002, 77300, 77301, 77334, 77336, and 77338).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert System.
You asked the Plan to pre-approve a Life Alert System. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says a Life Alert System is not covered by Medicare or the Plan.
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 Life Alert System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for defibrillator evaluation provided on September 12, 2019 by the out of network provider.
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 defibrillator evaluation provided on September 12, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on March 29, 2019.
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 indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low and high calibrator solution / chips (CPT Code A4256), spring-powered device for lancet, each (CPT Code A4258) and home blood glucose monitor (CPT Code E0607) provided to the enrollee from August 9, 2019 through October 28, 2019.

You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Of note, the Proof of Delivery is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (CPT Code A4253), lancets, per box of 100 (CPT Code A4259), normal, low and high calibrator solution / chips (CPT Code A4256), spring-powered device for lancet, each (CPT Code A4258) and home blood glucose monitor (CPT Code E0607) provided to the enrollee from August 9, 2019 through October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by, an in-network provider, from September 10, 2019 through September 17, 2019.

You asked the Plan to waive the copayment for inpatient hospital care. You say that due to the Plan not approving your discharge orders in a timely manner it created additional copay expenses. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states according to your account, the authorization for the inpatient hospital stay was approved for September 10, 2019 through September 16, 2019. The Plan states a review of the Health Plan's Authorization system shows that your skilled nursing facility pre-certification was submitted to the Health Plan on September 11, 2019, the Health Plan requested medical records necessary to render a determination on September 13, 2019 and the Health Plan received the medical records necessary to render a determination on September 16, 2019. The Health Plan's Medical Director then made the decision to deny the skilled nursing facility stay on September 17, 2019 and you were then discharged to home with home health care services. The Plan states there was no delay in processing the request.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted to an in-network provider, from September 10, 2019 through September 17, 2019. You were asked to pay a $325 copayment per day from September 10, 2019 through September 14, 2019, days 1-5 of your inpatient stay. There were no copayment charges from September 15, 2019, day 6 of your inpatient hospital care until your day of discharge September 17, 2019. Per your contract there is a $325 copayment per day required for days 1-5. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided by, an in-network provider, from September 10, 2019 through September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 27, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extra-abdominal omental flap (49904) provided on August 9, 2019.

You asked the Plan to pay for the extra-abdominal omental flap. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records did not include documentation of an extra-abdominal omental flap (for reconstruction of sternal and chest wall defects); therefore, this code cannot be verified.

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 49904 is omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects). 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 extra-abdominal omental flap. Our reviewer says that CPT 49904 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not contain documentation of an Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects) being performed on August 9, 2019, 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 extra-abdominal omental flap have not been met. Therefore, we decided that the Plan does not have to pay for extra-abdominal omental flap (49904) provided on August 9, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 20, 2019 to February 22, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a valid treatment authorization code is required and was not billed in box 63 on the claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required treatment authorization code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 20, 2019 to February 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium.
You asked the Plan to pre-approve the scan. You say that you are concerned about elevated blood pressure and cholesterol level. The Plan denied your request. The Plan says screening tests are not covered.
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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found you have some coronary risk, but have no cardiac symptoms or objective cardiac abnormalities. In this circumstance, the documentation does not support the medical necessity for screening coronary CT scanning. Guidelines currently do not recommend routine performance of specialized screening tests in the context of assessing coronary risk including screening coronary CT scanning. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was admitted for acute care with an exacerbation of chronic obstructive pulmonary disease and respiratory failure with 2 days of progressive worsening shortness of breath and a cough. The member lives with her husband and son in a single level residence with steps to the entrance and had been independent with a 4 wheeled walker during the day and a single-point cane at night when using the bathroom. As of 01/29/2020 she was able to ambulate 100 feet with a front wheeled walker and contact-guard assistance. She was able to perform lower body bathing and dressing with contact-guard assistance. She was able to follow multistep directions. The member is status-post acute care admission as described above and had previously ambulated at a modified independent level with a rolling walker. The member requires oversight of her medical conditions and medication management. She is at risk for recurrent complications related to her chronic obstructive pulmonary disease and co-morbid medical conditions. The member has not returned to her prior level of function. The member requires physical therapy for progression of her mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any home-based adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The member's condition would not be expected to deteriorate with services provided on a less than daily basis. The member's care can be appropriately provided through home-based and outpatient services. If stair climbing to access her residence is an issue, this would most appropriately occur on the actual stairs in the home setting. She has first-floor access and stair climbing within the home would not be an expected issue. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99238) provided on August 27, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation received shows that both emergency visits were essentially for the same reason, therefore only one will be allowed.
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Specifically, both evaluation and management services were for related problems. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99238) provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99204), a needle measurement and recording of electrical activity of muscles of arm or leg (95886), and nerve conduction studies (95913) to be provided by out of network provider.
You asked the Plan to pre-approve an office visit, a needle measurement and recording of electrical activity of muscles of arm or leg, and nerve conduction studies. You say that the network doctor's office (an in-network provider) recommended an OON doctor. The network doctor's office cannot accommodate you for services at this time. The Plan denied your request. The Plan says the same services are available within the network. You have already been approved to have the requested services performed by an in-network neurologist.
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 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. 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 an office visit (99204), a needle measurement and recording of electrical activity of muscles of arm or leg (95886), and nerve conduction studies (95913) to be provided by out of network provider.