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

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627) and chair (E1399).
You asked the Plan to pre-approve a seat lift mechanism and chair. You say that this device is medically
necessary for your condition. The Plan denied your request. The Plan says the rules for a seat lift mechanism
have 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. The rules also say that seat lift chairs are not covered. Coverage is
limited to a seat lift mechanism.
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 seat lift mechanism. Our reviewer
says that the requested seat lift mechanism is not medically necessary and reasonable. Our physician reviewer
found you are a 48-year-old male with a past medical history of hemiplegia and hemiparesis following cerebral
infarction. Based on the certificate of medical necessity provided there is no documentation that you have
severe arthritis of the hip or a neuromuscular disease, does not that a seat lift is included in the treating
practitioner's course of treatment, and does not show that a seat lift is likely to effect improvement your
condition or arrest or retard deterioration in the patient's condition.
Regarding the seat lift chair, this device is not covered by Medicare. Coverage is limited to a seat lift
mechanism.
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 seat lift mechanism and chair have not been met. Therefore, we decided that
the Plan does not have to pre-approve a seat lift mechanism (E0627) and chair (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is needed for the enrollee to regain baseline function. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that 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 surgical intervention for infection at site of prior pelvic orthopedic surgery. 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. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on March 25, 2020.

You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. The Plan says the diagnosis code does not substantiate the service.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is using insulin 3 or more times per day, but the documentation does not support that the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee on the basis of testing results. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on March 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision exam provided on October 19, 2020.

You asked the Plan to waive the copayment for the vision exam. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received vision exam services with an additional diagnosis and follow up from your surgery.

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 $35 copayment for Vision care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received vision exam services with an additional diagnosis and follow up from your surgery. You have been asked to pay a $35 copayment for the vision exam. The vision exam falls within the Vision care benefit category. 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 vision exam provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 physician services provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve proton beam radiation therapy (77523).
You asked the Plan to pre-approve proton beam radiation therapy. You say that the enrollee meets the criteria for coverage. The Plan denied your request. The Plan says that there is no benefit of this treatment over Intensity Modulated Radiation Therapy.
The Plan follows Medicare rules. Medicare rules say that coverage and payments of proton beam therapy for prostate cancer will require physician documentation of patient selection criteria and verification that the patient was informed of the range of therapy choices. 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 criteria for coverage have been met. Our physician reviewer found the LCD requires physician documentation of the patient "stage and other factors," which would include Gleason score and PSA, and documentation of the range of therapy choices, which is documented in the consultation note. The patient also agreed to consent to a registry study. 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 been met. Therefore, we decided that the Plan has to pre-approve proton beam radiation therapy (77523).
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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you have been in the hospital for 52 days and need care in the requested facility. The Plan denied your request. The Plan says you can be treated in the current hospital.
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 records provided, you are receiving appropriate care at the present acute care hospital. you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 14301) provided on November 18, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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 14301 is "Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm."

We asked our coding 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 reviewer says that the use of CPT code 14301 is not supported by the records provided. Our coding reviewer found that the operative report documents "excess mastectomy skin flap." This procedure is not an adjacent tissue transfer or rearrangement, therefore, CPT 14301 is an inappropriate code to report for the procedure performed.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 14301) provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar-sacral orthosis (L0650) provided October 20, 2020.

You asked the Plan to waive the copayment for the lumbar-sacral orthosis. You say that you would like this copayment waived because you are unable to use this orthosis. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 20% coinsurance for durable medical equipment. 

You have been asked to pay a total cost share of $182.68 for the lumbar-sacral orthosis ($913.40 allowed amount x 20% coinsurance). This item falls within the durable medical equipment benefit category. 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 lumbar-sacral orthosis (L0650) provided October 20, 2020.
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 SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 70-year-old female who was admitted to an acute care hospital for congestive heart failure, atrial fibrillation, and diabetes. In this case, there are identifiable skilled nursing needs and identifiable skilled therapy service needs. However, you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapeutic parenteral drug (D9610) provided on August 27, 2020.

You asked the Plan to pay forthe therapeutic parenteral drug. You say that tooth # 14 was abscessed. You also say that the provider encountered an infection.The Plan denied your request. The Plan says therapeutic parenteral drug is 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, therapeutic parenteral drug is not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay forthe therapeutic parenteral drug (D9610) provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99204) provided on December 9, 2020, by an out-of-network provider.

You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your request. The Plan says there is no evidence that the provider contacted the Plan to verify insurance, current eligibility, or authorization requirements. The Plan states the provider failed to request prior authorization before rendering services and there is also no evidence of plan directed care.

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 the office services (CPT code 99204) provided on December 9, 2020, by an out-of-network provider.
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 LTACH is medically necessary and appropriate.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 there is no evidence that the enrollee requires services that are not available at the current acute care hospital. As LTACHs and acute care hospitals 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 acute care hospital until such time as no acute services are required, then be transferred/discharged to a lower level ofcare 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0554 and K0553) provided on September 17, 2020.

You asked the Plan to pay for the continuous glucose monitor and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.

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.

We looked at the file and Medicare rules. The documentation submitted does not include any clinical information to verify if the member performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires 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 the continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0554 and K0553) provided on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
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 you were admitted to an acute care hospital for a stroke. Your medical problems are
stable. 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. Finally, 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (CPT code 90832) provided to the enrollee on September 10, 2020.

You asked the Plan to pay for the medical services. You say that you treated the enrollee while hospitalized and your provider cannot deny any medical services that were essential for the enrollee's health treatment. The Plan denied your request. The Plan says there is no evidence that the provider contacted the plan to verify insurance, current eligibility, or authorization requirements. The Plan states the provider failed to request prior authorization before rendering services. The Plan states there is also no evidence of plan directed care and the enrollee was not receiving skilled services or inpatient services at this time.

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 psychotherapy services (CPT code 90832) provided to the enrollee on September 10, 2020.