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

We decided that the Plan does not have to pre-approveintermittent limb compression device.You asked the Plan to pre-approveintermittent limb compression device. You say that the documentation provided supports payment for the claim in dispute.The Plan denied your request. The Plan says the physical exam documents no ulcers or lower extremity edema.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.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 intermittent limb compression device. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not meet coverage criteria and does not support the medical necessity of the device in question.  The medical records provided document that the enrollee was without complaints.  There is no documentation of problematic lymphedema or ulceration.  There is no documentation of any workup of these conditions and no documentation of efforts at a compression regimen.  There is no documentation in the medical record that any treatment for lymphedema or ulcerations was being considered and the plan was to follow up in six months.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met.Therefore, we decided that the Plan does not have to pre-approveintermittent limb compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator.

You asked the Plan to pre-approvethe portable oxygen concentrator. You say that the enrollee has been provided several oxygen tanks so that she can go for short rides. However, you say that the enrollee would like to travel to see family out of the area.The Plan denied your request. The Plan says no medical documentation supports the enrollee's need for a portable oxygen concentrator.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal isfor use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on June 16, 2020.
You asked the Plan to reduce the copayment for the office visit. You say that extra bills are stressful. You say that the cost should be $10. The Plan denied your request. The Plan says that the $45 copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $10 copayment for provider and professional services at an in-network PCP's office. The Plan says you must pay a $45 copayment for a specialist office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the office visit. The records do not show that the rendering provider is a specialist or that the visit was provided at a specialist's office. Therefore, we decided that the Plan has to reduce the copayment for the office visit provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic X-ray (D0330) provided on July 2, 2020.
You asked the Plan to pay for the panoramic X-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the service provided is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic X-ray (D0330) provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.

You asked the Plan to pre-approveIRF 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 above.

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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for diabetic ketoacidosis and pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF 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 above.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 requestedIRF 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 are living with a family member in a private home and are receiving home health services. You have had inpatient admissions in recent months for resection of a cerebellar brain tumor and for an infection after surgery. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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 ofIRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on June 19, 2020.You asked the Plan to waive the copayment for wound care. You say that you were told if you had a biopsy it might save money. The Plan denied your request. The Plan says the correct copayment has been applied.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 $275 copayment for outpatient surgery.You have been asked to pay a $275 copayment for wound care. Wound care falls within the outpatient surgery 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 an outpatient surgery provided by a participating provider on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dental services to be performed by an out-of-network provider.You asked the Plan to pre-approvethe dental services. You say that your gum is causing you pain and you were advised by your dentist that all your dental work must be done soon due to possible loosening of your teeth.The Plan denied your request. The Plan says you do not have out-of-network dental benefits.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 health plan contract says you must visit a participating dental network provider to receive dental benefits. 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-approvethe dental services to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the c opayment for chemodenervation and does not have to waive the coinsurance for Medicare Part B drugs provided on September 9, 2019.

You asked the Plan to waive the co payment for chemodenervation and to waive the coinsurance for Medicare Part B drugs. You say that you have never been charged in the past.The Plan denied your request. The Plan says he claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received chemodenervation on June 8, 2020. Therefore, you are responsible to pay the $50 copayment.You received Medicare Part B drugs provided on June 8, 2020. The total allowed amount is $1,224 and 20% of that is $244.80.The total amount you
owe is: $50 + $244.80 = $294.80.


You have been asked to pay the total amount of $294.80 for chemodenervation and Medicare Part B drugs. Chemodenervation falls within the physician/practitioner services, including doctor's office visits benefit categories. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 forchemodenervation and does not have to waive the coinsurance for Medicare Part B drugs provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetherapeutic CGM(CPT Code K0553).You asked the Plan to pre-approvethe DME. You say that the DME is necessary.The Plan denied your request. The Plan says the medical records do not show that the member tests four or more times a day.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 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 the DME have not been met. The medical records show that the member has diabetes and checks their blood sugars 2-3 times a day. CGM may be covered by Medicare if the member checks their blood sugars more than 4 times a day and inject insulin more than 3 times a day. The member's medical records show the enrollee does not check their blood sugar more than 4 times a day.Therefore, we decided that the Plan does not have to pre-approvetherapeutic CGM (CPT Code K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aquabeam transurethral waterjet ablation of the prostate
for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the
health problem.
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 the procedure. Our reviewer says that
the requested procedure is not considered medically reasonable and necessary in this case. Our physician
reviewer found Aquabeam transurethral waterjet ablation of the prostate is not medically necessary. The most
recent AUA Guideline update regarding surgical management of BPH states that aquablation may be offered to
patients with LUTS attributed to BPH provided prostate volume >30/<80g. In this case, the prostate gland is
too large to qualify for this procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve Aquabeam transurethral waterjet ablation of the prostate for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincision and subcutaneous placement of spinal neurostimulator for the enrollee.You asked the Plan to pre-approvethe surgery. You say that this is medically necessary.The Plan denied your request. The Plan says this 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 the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for the stimulator is not met. The enrollee has chronic back pain with no radicular component. The stimulator is not indicated for this medical condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met.Therefore, we decided that the Plan does not have to pre-approveincision and subcutaneous placement of spinal neurostimulator for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNFcare.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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-approveSNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary, as this provider is the only supplier of this device. The Plan denied your request. The Plan says there is no documentation of a trial of a more basic device.
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 the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee has lymphedema of the lower extremities only up to the knees, but there was no objective evidence of edema of the chest, trunk, or abdomen. There were no documented characteristics that would indicate a segmented pump over a standard pump for this enrollee. There is no documentation of a trial and failure of a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Flexitouch pneumatic compression device for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit services coded 99285 provided on June 24, 2020.
You asked the Plan to pay for the emergency department visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were billed incorrectly.
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 99285 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is supported in the medical record. Specifically, the plan is denying this claim due to an inappropriate diagnosis being billed. Review of the file shows that the services were billed with diagnosis codes Z1159, R42, R002, H538. Diagnosis code Z11.59 (Encounter for screening for other viral diseases) is a valid COVID-19 related diagnosis code to be billed with services. The documentation does not support why this diagnosis code cannot be billed with the services rendered. Based on this information, we decided that Medicare rules for coverage of the emergency department visit services have been met. Therefore, we decided that the Plan has to pay for the emergency department visit services coded 99285 provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora folding scooter (CPT Code K0899).You asked the Plan to pay fora folding scooter. You say that you picked a scooter that folds and can fit through your doors at home. You state that is needs to fold so it can fit in all vehicles so that you can get to appointments and otherplaces.The Plan denied your request. The Plan says a folding scooter for the purpose of travel is not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services withthe appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of a folding scooter have not been met.Medicare guidance says a power scooter is covered if you need it for home use. You mention you need to fold the scooter to fit into doors. This means that the scooter is not useful at home. It is useful for you to travel outside the home. This is not covered by Medicare. In addition, the code for folding scooter is not a Medicare covered code Therefore, we decided that the Plan does not have to pay fora folding scooter (CPT Code K0899).