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

We decided that the Plan does not have to pay forthe knee orthosis (L1851) and suspension sleeve (L2397) provided September 17, 2019.You asked the Plan to pay forthe orthoses. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says this enrollee is not eligible for telehealth services.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1851) and suspension sleeve (L2397)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be received in another setting.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is able to walk more than 100 feet. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 admission. You saythat the enrollee requires assistance for mobility.The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While theenrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octreotide Acet 50 mcg/ml vial You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approveOctreotide Acet 50 mcg/ml vial
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Repair Right Cornea, External Approach (08Q8XZZ) provided from June 3, 2019 to June 4, 2019.You asked the Plan to pay for Repair Right Cornea, External Approach. You say that the denial is incorrect, and the services were medically necessary.The Plan denied your request. The Plan says this is a non-covered procedure.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the procedures shown below are identified as always non-covered procedures:08Q8XZZ-Repair Right Cornea, External Approach.We find that code 08Q8XZZ-Repair Right Cornea, External Approach is not supported for payment. Specifically, this code is listed by Medicare as always a non-covered procedure. Based on this information, we decided that Medicare rules for coverage of Repair Right Cornea, External Approach have not been met. Therefore, we decided that the Plan does not have to pay forRepair Right Cornea, External Approach (08Q8XZZ) provided from June 3, 2019 to June 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forNebulizer, with compressor (E0570) provided on August 16, 2019 by an out of network provider.You asked the Plan to pay forthe nebulizer. You say that please reconsider this claim with the information provided.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 has network providers available who can provide 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 forNebulizer, with compressor (E0570) provided on August 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20mg Benicar Tablets.
You asked the Plan to pre-approve the Benicar. You say that this drug is medically necessary to help the member treat their condition. The Plan denied your request. The Plan says this is an oral medication that is not covered 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 20mg Benicar Tablets.
Benefits for the Benicar 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies codes as E2100, A4253, A4259. A4256, A4258 provided on July 16, 2019 to October 4, 2019.You asked the Plan to pay for the diabetic supplies. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says evidence of misrepresented services.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case.  The delivery ticket submitted did not include the carrier's tracking number, nordid the proof of delivery include an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies codes as E2100, A4253, A4259. A4256, A4258 provided on July 16, 2019 to October 4, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveAcicretin 25mg capsule.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is a medical only policy.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 Plandoes not haveto pre-approveAcicretin 25mg capsule.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency ambulance (A0428) ground mileage (A0425) provided  on September 14, 2019.You asked the Plan to pay forthe ambulance services. You say that this was an emergency transport and the enrollee had no choice as to who transported them. This claim is not related to hospice.The Plan denied your request. The Plan says Original Medicare would be responsible forpayment of all Medicare covered services related or unrelated to the member's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe non-emergency ambulance (A0428) ground mileage (A0425) provided  on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received from an out-of-network provider on July 13, 2019.You asked the Plan to pay forthe services. You say that the provider told you there would be no copayment.The Plan denied your request. The Plan says out-of-network services are not covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe services you received from an out-of-network provider on July 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating household distances. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on May 14, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at thefile and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 forthe drug testing services provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (code D6241) and 2 retainer crowns (code D6751).
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you need a second bridge. The Plan denied your request. The Plan says these services have a five-year time limit before they can be redone. The Plan also says that time limit has not yet passed.
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, both pontics and crowns are limited to once in a 5-year period. The record shows that you received an upper partial denture on December 4, 2018 and your pontic and crown benefits are now exhausted. Therefore, we decided that the Plan does not have to pre-approve a pontic (code D6241) and 2 retainer crowns (code D6751).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's care is not complex enough, and the enrollee can receive the care they need in a lower level of care.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is non-ambulatory at baseline and is already able to transfer with only contact guard assistance. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR) 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that it is felt that SNF care is necessary for his recovery.The Plandenied your request. The Plansaysthe enrollee's medical condition is stable and his level of function is such that daily skilled therapy is not needed.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male with a history of chronic obstructive pulmonary disease, atherosclerotic heart disease, atrial fibrillation and hypertension who suffered a cardiac arrest on 12/27/19. He was intubated and admitted to the coronary care unit of the acute hospital; he has since made significant recovery andis walking with a walker up to 125 feet as of 1/13/2020 and is requiring just contact guard assistance with transfers; stand by assistance with ADL's. At this time, there is no apparent need for daily skilled nursing services. Likewise, there is no evidence for a need for daily skilled therapy services. The provided medical records do not indicate a need for inpatient services in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for indwelling catheter (A4344) bedside drainage bag (A4357) urinary drainage bag (A4358) provided on September 10, 2019.
You asked the Plan to pay for urinary supplies. You say that CPT codes A4358, A4357 and A4344 is denied as non-covered services. The Plan denied your request. The Plan says these services are not covered by Medicare as they were not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Procedure codes A4344, A4357 and A4358 were not billed with a modifier. Based on this information, we decided that Medicare rules for coverage of urinary supplies have not been met. Therefore, we decided that the Plan does not have to pay for indwelling catheter (A4344) bedside drainage bag (A4357) urinary drainage bag (A4358) provided on September 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CTA of the legs for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says physical exam of the lower extremities was unremarkable.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is not medically reasonable and necessary. Our physician reviewer found the enrollee has no documented leg claudication symptoms (loss of leg strength does not equal claudication) and a normal lower extremity physical exam. Moreover, there is no documentation of any ankle-brachial index measurement to raise concern for lower extremity vascular insufficiency. In this circumstance, the records do not support the medical necessity for lower extremity CT angiography. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CTA of the legs for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Abiraterone tab 250mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication is a plan exclusion.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 Plandoes not haveto pre-approveAbiraterone tab 250mg for the enrollee