Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided during a gynecological surgery by a registered nurse first assistant (RNFA).

You asked the Plan to pay for the surgical assistant services. You say that the operative note clearly shows that these services were needed and should be paid. The Plan denied your request. The Plan says this type of provider is not able to be paid for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided during a gynecological surgery by a registered nurse first assistant (RNFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627).

You asked the Plan to pay for the seat lift mechanism. You say that you would like reconsideration because you were not aware that prior authorization was needed. The Plan denied your request. The Plan says this provider is not eligible to participate in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and Segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that this pump is medically necessary to be able to achieve long term goals. The Plan denied your request. The Plan says the enrollee does not have edema extending into the chest trunk or abdomen. A PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen is not eligible for reimbursement.

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 treatment with 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 not been met. Specifically, the record does not show that the enrollee has lymphedema extending into the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and Segmental pneumatic appliance (E0667).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a HHA 14 hours per week (G0156 x14 hours per week).

You asked the Plan to pre-approve the HHA. You say that you have a hard time walking, and need help bathing, cleaning, and cooking. The Plan denied your request. The Plan says the documentation does not show that you have a medical need for a HHA.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

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 HHA. Our reviewer says that the HHA is not medically reasonable and necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that there is no indication that you require skilled care and therefore the need for a HHA.

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 HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve a HHA 14 hours per week (G0156 x14 hours per week).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent transportation.

You asked the Plan to pre-approve the non-emergent transportation. You say that you would like reconsideration because you have a suspended license and need the services of a certified neurologist. The Plan denied your request. The Plan says non-emergent planned transportation is specifically not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve non-emergent transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the travel fee (D9999), and a house or extended care facility call (D9410).

You asked the Plan to pre-approve the travel fee and extended care facility call. You say that after removing the distal decay from tooth and preparing the tooth for a crown, there will not be enough tooth structure remaining to retain a crown. The Plan denied your request. The Plan says a travel fee is not listed as a covered service. The Plan says that extended care facility call is not listed as a covered service either.

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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve the travel fee (D9999), and a house or extended care facility call (D9410).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ability drive-eye drive system, a power seat elevation
system, a quantum back up camera and a stealth elbow support.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that these items are not reasonable and necessary for your condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules say that a power seat elevation feature is non-covered because it is not
primarily medical in nature. The rules say Medicare covers DME only when it is reasonable and necessary. If
DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable
and necessary. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.

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 an ability drive-eye drive system. Our
reviewer says that an ability drive-eye drive system is not considered medically reasonable and necessary in
this case. The requested ability drive-eye drive system is not FDA approved. It is not found to be safe and
effective for your condition. Our physician reviewer found that your condition does not meet Medicare criteria
for an ability drive-eye drive system.

We looked at this physician's review, the file, and Medicare rules. The quantum back up camera at issue in this
appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. The file shows that you have the power
wheelchair the Plan has approved comes with elbow pads. A stealth elbow support serves the same purpose as
elbow pads. Therefore, we decided that the Plan does not have to pre-approve an ability drive-eye drive system,
a power seat elevation system, a quantum back up camera and a stealth elbow support.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance (E0486).

You asked the Plan to pre-approve an oral appliance. You say that you were told this would be covered. The
Plan denied your request. The Plan says the criteria for coverage were not met.

The Plan must follow Medicare rules. Medicare rules say that a custom fabricated mandibular advancement
oral appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered only if the enrollee's apneahypopnea
index (AHI) is greater than or equal to 5.

We looked at the file and Medicare rules. The record shows that your AHI is 2.4. Based on this information, we
decided that Medicare rules for coverage of an oral appliance have not been met. Therefore, we decided that the
Plan does not have to pre-approve an oral appliance (E0486).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the garamycin, gentamicin injection (J1580x80).

You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the number of units billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We asked our coder 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 injection. Our reviewer says that CPT code J1580x80 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that an injection, garamycin, gentamicin, up to 80 mg was performed on June 26, 2020, therefore, this service cannot be verified.

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 injection have not been met. Therefore, we decided that the Plan does not have to pay for the garamycin, gentamicin injection (J1580x80).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for destruction by neurolytic agents (64635, 64636, 64640) and
methylprednisolone acetate(J1030).

You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We asked our coder 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 injections. Our reviewer says that CPT codes 64635,
64636, 64640 and J1030 do not meet criteria for billing or reimbursement consideration. Our reviewer found
the medical records provided do not include sufficient documentation of Destruction by neurolytic agent,
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet
joint. 64636 is an add-on code and is not separately payable if the primary procedure code is not eligible for reimbursement. The medical records provided do not include documentation of a Destruction by neurolytic agent; other peripheral nerve or branch; therefore, this service cannot be verified. The medical records provided do not include documentation of an
Injection, methylprednisolone acetate, 40 mg.

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 injections have not been met. Therefore, we decided that the Plan does not
have to pay for destruction by neurolytic agents (64635, 64636, 64640) and methylprednisolone acetate(J1030).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says a valid proof of delivery was not returned.

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 does not contain a valid proof of delivery. In this case, the proof of delivery was returned without a signature. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 thoracolumbar decompression and fusion and has been discharged home with home health care. 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, in 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.

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: 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 the treating physician feels the enrollee meets all of the criteria for IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the record supports need for physical and/or occupational therapy, it does not support need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650).

You asked the Plan to pre-approve a lumbar-sacral orthosis. You say that the item is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation indicating the medical necessity of the item.

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 a lumbar-sacral orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Specifically, there is insufficient documentation of a credible evaluation and a credible physical examination of the back. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (L0650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion with an OON oncology provider.

You asked the Plan to pre-approve the second opinion with an OON oncology provider. You say that you are
already at stage four cancer in the lining of the lungs. You say that it is of the utmost importance to receive
treatment that could extend your life, as surgery is not a valid option for you. You say that you want to know if
there are any other alternative treatment options available that are different from your current treatment with
the in-network oncologist. The Plan denied your request. The Plan says the enrollee's condition does not meet
the rules for approval of an HMO exception for OON services.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.

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 second opinion with an OON
oncology provider. Our reviewer says that the criteria for OON coverage have not been met. Our physician
reviewer found the Plan is offering adequate care to meet the enrollee's medical needs through a referral to an
in-network oncologist. The enrollee has started therapy for her stage IV lung cancer. The medical records
provided do not demonstrate that there is anything unique about the enrollee's condition that would make it
medically necessary to see the requested OON provider. The plan has shown that they have in-network
providers who meet the Standards of Care required for treatment of the enrollee's 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 second opinion with an OON oncology provider have not been met.
Therefore, we decided that the Plan does not have to pre-approve a second opinion with an OON oncology
provider.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 pneumonia and a pulmonary embolism. 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, in 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.

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.