Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit.

You asked the Plan to pay for the domiciliary or rest home. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 for a domiciliary or rest home visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the enrollee is using the requested medically necessary items with benefit. The Plan denied your request. The Plan says there is no documentation of a video or telephonic visit by the ordering physician to warrant the codes billed.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis and suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis have not been met. Additionally, the requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy. 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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve fractional flow reserve testing.

You asked the Plan to pre-approve fractional flow reserve testing. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 fractional flow reserve testing. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found assessment of the already known established underlying coronary disease's physiologic significance by non-invasive fractional flow reserve, in conjunction with the coronary computed tomography angiography (CCTA), is medically reasonable and necessary and meets the CMS Section 1862(a) applicable criteria here.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fractional flow reserve testing have been met. Therefore, we decided that the Plan has to pre-approve fractional flow reserve testing.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).

You asked the Plan to pre-approve a power seat elevation system. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is non-covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after presented to the emergency department with bed bugs. She was discharged from physical and occupational therapy and was independent with bed mobility, transfers, toilet transfers, and lower body dressing. She had no skilled nursing or skilled therapy needs. She did not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting. Your needs can be met in the current facility until you are ready for a discharge to the community or home setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.

You asked the Plan to pre-approve 8 additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 8 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found based on the available records you appear to have improved with therapy to the point of being able to manage day to day activities such as walking and carrying objects. Further skilled therapy at this point does not appear to be necessary and transition to a home exercise program appears appropriate at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery to repair a ruptured musculotendinous cuff.

You asked the Plan to pre-approve the shoulder surgery to repair a ruptured musculotendinous cuff. You say that the surgery is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet CMS guidelines for authorization and therefore is considered 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 shoulder surgery to repair a ruptured musculotendinous cuff. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 73-year-old female that was being treated for rotator cuff tear or rupture right shoulder. She presented with progressive right shoulder pain with overhead activities, lateral pain, and night pain. Exam of the right shoulder reveals positive impingement signs. There is tenderness along the biceps and AC joint with pain at the AC joint with cross body adduction. She continues to have severe disabling pain which is progressive in nature. She has rotator cuff tear arthropathy with calcification in the bursa, there is a large subacromial spur. However, detailed documentation is not evident regarding a trial and failure and outcomes of applicable recent, reasonable and comprehensive less invasive conservative care measures. Furthermore, detailed documentation is not evident regarding any updated MRI of the right shoulder post-operative in order to further delineate ongoing pathology. Progressively painful overhead activities were noted, as was non-detailed shoulder motion and atony. The noted combination of these findings, especially unclear current passive, active shoulder range of motion details, and deltoid atony, present a lack of clinical clarity regarding shoulder motion capabilities and adequacy of deltoid motor strength and function overall. Unclear motion documentation and/or plausible severely impaired deltoid strength deficit represent potential contraindications to the requested procedure, as per the literature guidelines. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for elective shoulder surgery to repair a ruptured musculotendinous cuff is not medically reasonable or 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 shoulder surgery to repair a ruptured musculotendinous cuff have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder surgery to repair a ruptured musculotendinous cuff.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered.

You asked the Plan to waive the deductible for these services. You say that you were not given advanced notice about the charges. The Plan denied your request. The Plan says the deductible was 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 there is $1,000 yearly deductible for your covered medical services.

The services you asked the Plan to waive the deductible for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services with current procedural terminology (CPT) codes 29827 and 29826 provided on June 21, 2019.
You asked the Plan to pay for CPT codes 29827 and 29826. You say that the medical records support the billing of CPT codes 29827 and 29826 provided on June 21, 2019. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 29827 and 29826 provided on June 21, 2019.
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 29827 is Arthroscopy, shoulder, surgical; with rotator cuff repair. The CPT Cod Manual definition of code 29826 is Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT codes 29827 and 29826. Our reviewer says that the medical records do not support the billing of CPT codes 29827 and 29826 provided on June 21, 2019. Our physician reviewer found both codes should not be billed. The 29827 code is not supported by the operative note. As there was no rotator cuff repair conducted. Also, the code 29826 is not supported as the acromioplasty is not described in the operative note. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 29827 and 29826 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services with current procedural terminology (CPT) codes 29827 and 29826 provided on June 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the patient screening (D0190 x 2) provided from December 7, 2020, to December 9, 2020.

You asked the Plan to pay the in network rate for the patient screening. You say that you would like the remaining balance to be paid for. You say that you cannot afford to pay it. You say that the dental office is at fault for sending you a dentist that was out of network without your knowledge. You also say that you were told everything was covered and you would owe nothing. The Plan denied your request. The Plan says patient screening is not listed as a covered service. The Plan also says that any services not listed are not covered.

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, patient screening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the patient screening (D0190 x 2) provided from December 7, 2020, to December 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that Keytruda is medically reasonable and necessary or safe and effective for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the elective shoulder arthroplasty surgery may be safely performed with an observational stay for 48 hours. Inpatient admission is not medically needed for this routine surgery. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the enrollee has mental fog due to her prior COVID diagnosis. She now requires caregiver assistance with managing her diabetes. Dexcom has a companion app to allow her caregiver to review her readings which Freestyle Libre does not. The Plan denied your request. The Plan says it was confirmed that the Freestyle Libre 2 offers the LibreLinkUp app which will allow for caregiver monitoring of blood sugar levels.

The Plan must follow Medicare rules. Medicare rules say that Plans may restrict enrollees to certain brands for DME as long as all medically necessary DME is available. 

In this case, the feature which is noted to be necessary is available with the preferred brand. There is no other documentation to support that the Freestyle Libre 2 CGM would not meet the enrollee's needs. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).