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

We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT code K0823), power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (CPT Code E2365) and adjustable height, detachable armrest, complete assembly, each (CPT Code E0973), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says there is no documentation why the enrollee needs the wheelchair.

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. 

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 DME. physician reviewer found the K0823 power mobility device with E0973 adjustable detached arms desk full and E2365 sealed lead acid battery criteria have not been met per LCD: Wheelchair Options/Accessories (L33792). The documentation reveals that the enrollee has mobility deficit that interferes with MRADLs and is unable to be effectively helped by a cane, walker, or manual wheelchair due to falls and weakness. The November 6, 2020, home environment evaluation document has a question asking if the enrollee's home provides adequate access between rooms, maneuvering space and surfaces for the use of the equipment being provided and the box "no" is checked off.

Therefore, the documentation does not support that this K0823 device would significantly improve MRADL participation in the home or would be safe for the enrollee to use in the home. The requested K0823 and the associated E0973 adjustable detached arms desk full, and E2365 sealed lead acid battery are not medically necessary. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds (CPT code K0823), power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (CPT Code E2365) and adjustable height, detachable armrest, complete assembly, each (CPT Code E0973), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over-bed table (E0274).

You asked the Plan to pre-approve an over-bed table. You say that this item is necessary for your condition. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an over-bed table (E0274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because the member should be started on this treatment as soon as possible. The Plan denied your request. The Plan says the requested provider is not in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the office visit 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 alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less (A6169) provided November 17, 2020.

You asked the Plan to pay for the surgical dressings. You say that you rendered medically necessary services at the request of the SNF/PCP, the CPT denied as bundled is submitted with modifier, please review. The Plan denied your request. The Plan says this service is bundled into the primary covered services and cannot be billed separately.

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, we have confirmed that code the surgical dressings has a bundled relationship with code 11043 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less (A6169) provided November 17, 2020.
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3D imaging.

You asked the Plan to pre-approve the 3D imaging. The Plan denied your request. The Plan says the 3D imaging 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 3D imaging. Our reviewer says that the requested 3D imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found that the MRA showed anterior communicating artery aneurysm. 3D imaging was requested. The enrollee was not planned to undergo surgery or have a complex fracture to justify the 3D imaging. The MRA already revealed aneurysm. No clarification required and the proposed imaging was not explained to help improve the overall outcome of the patient. Therefore, this request for 3D imaging will be considered not medically necessary. 

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 3D imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested 3D imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions to be performed by an out-of-network provider.

You asked the Plan to pre-approve the dental extractions. You say that the surgery is needed for your teeth due to the fact that you take Zoloft and morphine and it causes decay. The Plan denied your request. The Plan says the dental extractions you request could be approved if provided by an in-network provider. The Plan states you can find a list of in-network providers in your Provider Directory.

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. 

Your records show you have tooth infections, you do not have broken bones in your face or jaw, or have cancer and need tooth removal in preparation for radiation. Therefore, we are unable to approve the dental services under your medical benefits. Furthermore, your supplemental dental plan states you pay 100% for out-of-network dental services. 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 dental extractions to be performed by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).

You asked the Plan to pre-approve the knee orthosis. You say that the enrollee has instability in the right knee while she is walking, and right knee severe medial compartment osteoarthritis. The Plan denied your request. The Plan says the requested knee orthosis is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). 

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 knee orthosis. Our reviewer says that a knee orthosis is not medically reasonable and necessary for the enrollee. Our physician reviewer found the documentation does indicate the enrollee is ambulatory. The documentation does not indicate that the enrollee had a recent injury to or a surgical procedure on the knee(s) or objective knee instability documented by examination of the enrollee with an objective description of joint laxity. Our reviewer also found that the L1843 orthosis criteria per Local Coverage Determination (LCD): Knee Orthoses (L33318) have not been met and therefore the L1843 is not medically necessary. 

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1843).
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 congestive heart failure, acute kidney injury, acute respiratory failure, gastrointestinal bleeding with anemia. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for a right hip abductor tendon repair and suture of quadriceps or hamstring muscle rupture services.
You asked the Plan to pre-approve inpatient admission. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are 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 inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has full thickness tear of right gluteus medius tendon with tearing of right gluteus minimus tendon associate with trochanteric bursitis. The documentation does not reflect a severity or illness to meet the inpatient criteria. There is no specific clinical rationale for the requested inpatient services. Therefore, the enrollee does not meet criteria for the requested inpatient 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for a right hip abductor tendon repair and suture of quadriceps or hamstring muscle rupture services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Humira Pen
You asked the Plan to pre-approve the Humira Pen. You say that you would like reconsideration because this drug is medically necessary to prevent additional episodes. The Plan denied your request. The Plan says Humira does not fall under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Humira Pen
Benefits for the Humira Pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
You asked the Plan to pre-approve interspinous spacer placement. You say that the spinal spacer is medically necessary. The Plan denied your request. The Plan says the requested interspinous spacer is considered investigational and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve PSG; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of CPAP therapy or bilevel ventilation, attended by a technologist (CPT code 95811), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says that the enrollee's doctor did not say that the enrollee had health problems that warrant a facility sleep study.
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 service. physician reviewer found an attended PSG with PAP titration is considered reasonable and necessary for this enrollee. The enrollee was previously diagnosed with obstructive sleep apnea (OSA) more than 20 years ago, and had done well on CPAP. However, the original sleep findings are unknown, and the CPAP pressure is unknown. The enrollee is having return of sleep symptoms, and has excessive daytime sleepiness. Given the return of symptoms, and the length of time since original diagnosis, it is reasonable to obtain a new PSG to confirm the diagnosis and establish the PAP settings, prior to providing a new device. A home sleep study is not an alternative because it will not be of benefit in this situation. 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 service have been met. Therefore, we decided that the Plan has to pre-approve PSG; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of CPAP therapy or bilevel ventilation, attended by a technologist (CPT code 95811), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power wheelchair.
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power wheelchair.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Selegiline 5MG Cap, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says this medication is covered under Part D benefits, but the enrollee does not have Part D benefits. The Plan states this medication does not fall under the members Part B benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Selegiline 5MG Cap, for the enrollee.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the fluoroscopic guidance and injections provided on September 8, 2020 and September 22, 2020.
You asked the Plan to waive the cost share for the fluoroscopic guidance and injections. You say that you called to confirm your doctor was in-network. You say that the claims should be processed as in-network instead of out-of-network. The Plan denied your request. The Plan says the cost share applied correctly.
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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at a free-standing facility (such as a radiology center or medical clinic) and 20% coinsurance for each Medicare-covered Part B drug from an in-network provider. You have been asked to pay a total of $185.50 for the fluoroscopic guidance and injections.
Date of Service
Service
Allowed Amount
Standard Cost
Member Liability
September 8, 2020
Fluoroscopic Guidance
$115.02
$110
$110
September 8, 2020
Synvisc Injection
$179.04
20%
$35.81
September 22, 2020
Synvisc Injection
$179.04
20%
$35.81
September 22, 2020
Methylprednisolone Injection
$18.27
20%
$3.65
September 22, 2020
Drug Injection
$2.65
20%
$0.53
TOTAL:
$185.50
The fluoroscopic guidance falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The injections fall within the "Medicare Part B Prescription Drugs" benefit category. The records show that you were charged the in-network rate. 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 cost share for the fluoroscopic guidance and injections provided on September 8, 2020 and September 22, 2020.