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

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair.

You asked the Plan to pre-approve a Group 2 power wheelchair (K0823). You say that you need a Group 2 power wheelchair. The Plan denied your request. The Plan says clinical documentation supporting criteria was requested from your provider but not received.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair or you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies and drugs provided/used during anesthesia services for a screening colonoscopy on September 11, 2020.

You asked the Plan to pay for the supplies and drugs. You say that these services are rendered in an office setting, so the supplies must be brought to the surgery by the provider. As such, these supplies must be reimbursed. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. Medicare rules say that separate payment cannot be made for drugs, supplies, and materials used in anesthesia care. Therefore, we decided that the Plan does not have to pay for the supplies and drugs provided/used during anesthesia services for a screening colonoscopy on September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve the genetic testing. You say that this test is medically necessary. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for genetic testing for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene except for pregnant patients. We looked at the file and Medicare rules. The records do not show the enrollee is pregnant. This test is only covered for pregnant patients under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the total electric hospital bed provided from
November 20, 2020, to December 19, 2020.
You asked the Plan to reimburse you for the total electric hospital bed. You say that the total electric hospital
bed helps you get in and out easier and you wake up with less pain. The Plan denied your request. The Plan
says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to reimburse you for the total electric
hospital bed provided from November 20, 2020, to December 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services (99204) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network acupuncture services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve acupuncture services (99204) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
January 22, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had a phone call
with the nurse practitioner and did not see the doctor. This copayment is too high and there should be no
copayment for a virtual visit. The Plan denied your request. The Plan says you have been asked to pay 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 a $45
copayment for each in-network Medicare-covered visit with a specialist.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
you were charged separately for the office visit. 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 the
specialist office visit provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat-lift mechanism (E1399).
You asked the Plan to pre-approve the seat-lift mechanism. You say that the seat-lift mechanism is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. 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 seat-lift mechanism. Our reviewer says that the seat-lift mechanism is not medically necessary. Our physician reviewer found the record shows that the patient does not have severe arthritis of the hip or a neuromuscular disease. The records do not show that a seat lift is included in the treating practitioner's course of 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 the seat-lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat-lift mechanism (E1399).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and materials provided on January 19,
2021.

You asked the Plan to pay for the services provided. You say that the scans were required to determine the
success of the chemotherapy drugs. The Plan denied your request. The Plan says there is no separate
reimbursement for bundled codes.

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 99072 is additional supplies, materials, and clinical staff
time over and above those usually included in an office visit or other non-facility service(s), when performed
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is a bundled code. Payment for services is bundled into payment for other
covered services. This code is not separately payable. Therefore, we decided that the Plan does not have to pay
for additional supplies and materials provided on January 19, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.

You asked the Plan to pre-approve a CardioMEMS device. You say that the requested CardioMEMS device is medically necessary for the enrollee. The Plan denied your request. The Plan says that this device is considered experimental and is not medically necessary at this time.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the patient has NYHA Class III heart failure with preserved ejection fraction and is on a high dose oral diuretic regimen as well as intermittent outpatient IV diuretics with recent emergency department visits. He has moderately severe pulmonary hypertension and chronic atrial fibrillation. Management of his heart failure with standard medical therapy and relying on symptoms, weights and signs has not been effective in keeping him with minimal symptoms and has resulted in recent hospital presentations requiring IV diuretics due to severe fluid retention. CardioMEMS pressure sensor device monitoring in this situation can provide additional heart filling pressure data to better manage very complex regimens to optimize fluid status. Data from the Champions trial along with longer term follow-up studies have shown a significant decrease in hospitalizations and improvement in heart failure symptoms and NYHA Class with the use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use as well as reasonable patient selection criteria, and FDA approved indications all of which are met in this clinical instance. Given the severe symptoms of recurrent CHF which appears very sensitive to volume loading conditions, the complexity of the IV and oral diuretic regimen, and the high likelihood of hospitalization for decompensated CHF at any time, the use of the CardioMEMS pulmonary pressure sensor device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one.

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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS device.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for back pain and was treated for discitis. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 2 hours of home infusion administration (99601) and
each additional hour of home infusion or specialty drug administration (99602) provided on September 29,
2020.

You asked the Plan to pay for the home infusion services. The Plan denied your request. The Plan says the
denial of payment for these services is correct, because the billed code is not valid for Medicare purposes and is
not covered.

The Plan must follow Medicare rules. Medicare rules say that procedure codes 99601 and 99602 are not valid
for Medicare purposes and are not payable.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to
pay for the first 2 hours of home infusion administration (99601) and each additional hour of home infusion or
specialty drug administration (99602) provided on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for post-operative complications/abscesses. The enrollee has undergone abscess drainage and is receiving antibiotics therapy. The enrollee is eating on her own and 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 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on November 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on November 6, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 9, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the breast implant removal procedure provided on December 21, 2020 to December 22, 2020 by an out of network provider.

You asked the Plan to reimburse you for the breast implant removal procedure. You say that your implants had ruptured so you needed the surgery. Plan denied your request. The Plan says you did not request prior authorization for the procedures.

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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare rules say no Medicare payment may be made to a beneficiary for services provided directly by a provider who is not eligible to take Medicare payment. 

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 services at issue in this appeal. The Plan did not pre-approve the services at issue.

The provider is not enrolled in Medicare. We found no exception that would require the Plan to reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for the breast implant removal procedure provided on December 21, 2020 to December 22, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for nonsurgical management of a subdural epidural after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the anesthesia services provided on December 18, 2020.
You asked the Plan to waive the coinsurance for the anesthesia services. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the services have been processed per the enrollee's plan benefits.
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 $1000 deductible for that the enrollee has to pay out-of-pocket before the plan will pay their share for the enrollee's covered medical services. The enrollee has been asked to pay a $1000 deductible for the anesthesia services. The anesthesia services fall within the that the deductible 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 coinsurance for the anesthesia services provided on December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig (A9282).

You asked the Plan to pre-approve the wig. You say that the wig is medically necessary as you suffer from hair loss following COVID-19 infection. The Plan denied your request. The Plan says a wig is not a covered item.

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 (A9282).