Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy provided on November 7, 2019.
You asked the Plan to pay for the medical nutrition therapy. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy provided on November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen and pelvis and a CTA of the chest to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a CTA of the abdomen and pelvis and a CTA of the chest provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are in-network providers available to you that can provide the CTA's being requested.

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 computed tomographic angiography (CTA) of the abdomen and pelvis and a CTA of the chest to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle orthoses (L1971, L3170) and neuromuscular stimulator supplies (E0745, A4595) provided on September 18, 2020.

You asked the Plan to pay for the ankle orthoses and neuromuscular stimulator. You say that you would like reconsideration because the equipment billed was medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the ordering physician and member.

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 pay for the ankle orthoses and neuromuscular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. There is insufficient documentation of a credible physical examination of the ankles and feet.

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 ankle orthoses and neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the ankle orthoses (L1971, L3170) and neuromuscular stimulator supplies (E0745, A4595) provided on September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says the criteria for LTACH care are not met.

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 was admitted to the acute care hospital with respiratory failure due to COVID-19. The enrollee was intubated. A tracheostomy and PEG tube were placed. The enrollee remains on a mechanical ventilator. The enrollee developed acute renal failure, and hemodialysis was started. It is noted that the enrollee suffered an acute stroke with a small subarachnoid hemorrhage. The enrollee was lethargic and was not following commands. It is documented that the enrollee developed a fever overnight. The enrollee is anemic and neutropenic. New blood cultures were sent. There is suspicion for a fungal infection. Culture results are pending.

Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cologuard testing you received on September 21, 2020.

You asked the Plan to pay for the Cologuard testing. The Plan denied your request. The Plan says the coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered when the NCD coverage criteria are met.

We looked at the file and Medicare rules. The records show that you are 46 years old. The NCD coverage rules require you to be between the ages of 50 and 85 for coverage to be considered. Based on this information, we decided that Medicare rules for coverage of the Cologuard testing have not been met. Therefore, we decided that the Plan does not have to pay for the Cologuard testing you received on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0481) provided to the enrollee on July 2, 2020.

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 the records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (CPT 80307 and HCPCS G0481) provided to the enrollee on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 3 power wheelchair upgraded electronics.

You asked the Plan to pre-approve the power wheelchair joystick controller module (K0108), Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs a Group 3 power wheelchair, accessories and upgraded electronics. The Plan denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches.

The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.

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 Group 3 power wheelchair joystick controller module or upgraded electronics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on August 10, 2020.
You asked the Plan to pay for the 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 rendered 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. Cardiovascular disease screening tests are only covered for certain indications. The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on August 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on December 3, 2020.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was been submitted with an invalid modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 90837 is not supported in the record. Specifically, per Medicare modifier GT has been eliminated for telemedicine services. Additionally, the place of service code 11 indicating that this service was rendered in an office setting. Place of service code 02 certifies that the service meets telehealth requirements. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Botox. Our reviewer says that the criteria for coverage of Botox have not been met. Our physician reviewer found the Plan requires a trial of Xeomin before they will approve the requested drug, Botox. Based on the medical records provided, the enrollee has not tried and failed the required drug. There is no indication that the plan's required drug would likely be less effective or have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 24, 2020, to October 31, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you would like this service covered. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1 through 20 and a $178 copayment per day for days 21 through 100 for Skilled Nursing Facility (SNF) care up to an in-network maximum out-of-pocket amount of $6,700 for 2020. At the time this claim was processed, $4,522.91 of the $6,700 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 35 days, which were days 1 to 35 of the benefit period, resulting in a total copayment amount of $2,177.09 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $6,700 in-network maximum out-of-pocket amount for 2020. The enrollee has been asked to pay a $0 copayment per day for days 1 through 20 and a $178 copayment per day for days 21 through 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided from September 24, 2020, to October 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on March 25 to April 25, 2020, by an OON provider.

You asked the Plan to pay for supplies for a CGM. You say that the requested items were medically necessary for ongoing service to the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

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 had network providers available who could have provided 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 supplies for a therapeutic CGM (K0553) provided on March 25 to April 25, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided October 16, 2020.
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 99291 is a critical care visit of 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not document how much time was spent on these services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (K0553, K0554), disposable sensor for use with interstitial continuous glucose monitoring system (A9276) and external receiver for use with interstitial continuous glucose monitoring system (A9278).
You asked the Plan to pre-approve the therapeutic continuous glucose monitor, disposable sensor for use with interstitial continuous glucose monitoring system, and external receiver for use with interstitial continuous glucose monitoring system. You say that these items are medically necessary. The Plan denied your request. The Plan says these are not covered services.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. The rules also say that the items described by codes A9276 and A9278
describes a CGM system that does not meet the criteria for coverage of a therapeutic CGM system. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. The other items requested are not Medicare-covered CGM systems. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor, disposable sensor for use with interstitial continuous glucose monitoring system, and external receiver for use with interstitial continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (K0553, K0554), disposable sensor for use with interstitial continuous glucose monitoring system (A9276) and external receiver for use with interstitial continuous glucose monitoring system (A9278).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 sensor.
You asked the Plan to pre-approve Dexcom G6 sensor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day and use insulin with at least three daily injections. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 sensor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you need therapy. The Plan denied your
request. The Plan says the admission 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 in the Medicare rules section 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted
to the hospital on April 24, 2021, with an ankle fracture and underwent surgical repair. You had stable vital
signs and were treated for pain. You received physical and occupational therapy in the hospital and need
assistance with walking 200 feet with a knee scooter and 80 feet with a rolling walker. You need varied levels
of assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs
but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary
services on an inpatient basis at the SNF level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network
provider.
You asked the Plan to pre-approve physical therapy with an out-of-network provider. You say that the
requested physical therapy provider is more convenient for you. The Plan denied your request. The Plan says
they have in-network providers who can meet your needs.
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
physical therapy to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092, R0070) provided on October 14, 2020.
You asked the Plan to pay for the transportation and set-up of a portable x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes R0070 and Q0092 has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the 2020 National Physician Fee Schedule Relative Value File October Release.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set-up of a portable x-ray have not been met. Specifically, this claim was billed with place of service code 31 indicating that the member was in a Part A SNF stay. When the member is in a Part A stay, the transportation and set-up costs are not separately billable to Medicare Part B. Therefore, we decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092, R0070) provided on October 14, 2020.