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

We decided that the Plan does not have to pay for the fully electric hospital bed provided on December 28, 2020.
You asked the Plan to pay for the fully electric hospital bed. You say that this was medically necessary. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the fully electric hospital bed provided on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the item is necessary as you cannot stand in the shower due to severe pain. The Plan denied your request. The Plan says this item is a non-covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteotomy surgery.
You asked the Plan to pre-approve osteotomy surgery. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested surgery is not medically necessary and reasonable
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 osteotomy surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is not enough clinical information to justify the need for osteotomy surgery. There are no Cobb angle measurements and deformity measurements. More information is needed. in addition, the requested Trinity allograft matrix bone grafting is experimental, and more research is needed to justify its use in the anterior cervical spine.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of osteotomy surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve osteotomy surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 10, 2021.

You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance services is not medically necessary. Our physician reviewer found that upon the ambulance arrival, emergency medical services staff reported that the patient was having weakness and new onset of cough. The enrollee was found sitting with normal work of breathing, sporadic cough, and normal sinus cardiac rate. The blood pressure was 110/77, cardiac rate 86, respiratory rate 14, and oxygen saturation 95%. The Glasgow coma scale was 14 in this dementia patient. The enrollee was hemodynamically stable with stable vital signs. The review indicates that the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on January 10, 2021.

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 Ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on January 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a forensic inpatient psychiatric hospitalization.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for services rendered to
individuals in custody of penal authorities.
We looked at the file and Medicare rules. The file shows that the enrollee is in custody. 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 pre-approve a forensic inpatient psychiatric hospitalization.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). You say that the enrollee needs the procedure for low back pain relief. The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain
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 Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure. The FDA approved the device, but not the procedure. Any suggestion to the contrary is false and misleading. The request 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 Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 29,
2021.

You asked the Plan to waive the copayment for a laryngoscopy. You say that this is part of your cancer
treatment and you cannot afford the charges and cannot receive further treatment if the charges are going to be
this high. The Plan denied your request. The Plan says the claims were processed correctly, and you are being
charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295
copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received a laryngoscopy on January 29, 2021, at an outpatient hospital facility. A laryngoscopy is
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.

You have been asked to pay a $295 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive back surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve minimally invasive back surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to perform the surgery you need.
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 minimally invasive back surgery 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 pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is medically necessary due to extreme soreness of fingers. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health/hospice aide in home health or hospice settings, each 15 minutes (G0156).
You asked the Plan to pre-approve the home health services. You say that the enrollee is wheelchair bound. You say that the enrollee is homebound. You also say that the enrollee cannot do anything on her own, especially bathing. The Plan denied your request. The Plan says the enrollee does not have any skilled needs. The Plan also says that the enrollee is not homebound.
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 home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that the requested services are custodial in nature and do not required skilled professionals. Therefore, the reviewer found that the requested home health services 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health/hospice aide in home health or hospice settings, each 15 minutes (G0156).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The
Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee continues to receive acute critical care services and these have not been
denied. The medical record does not indicate that the enrollee requires services that he is not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied. The requested service cannot be recommended.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interprofessional consultation (99449) provided on November 2, 2020.

You asked the Plan to pay for the interprofessional consultation. You say that you would like reconsideration because both services were rendered and should be paid. The Plan denied your request. The Plan says because the enrollee had a personal evaluation and management service (99443), the use of code 99449 is not appropriate.

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 interprofessional consultation. Our reviewer says that CPT code 99449 does not meet criteria for billing or reimbursement consideration. Our reviewer found documentation includes a non face-to-face visit with enrollee, therefore CPT 99449 in an inappropriate code to report for this service. CPT 99449 is to be reported when "interprofessional" management services are provided, and would not have interactions with the patient for this service. There is a more appropriate evaluation and management code to report. 

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 interprofessional consultation have not been met. Therefore, we decided that the Plan does not have to pay for the interprofessional consultation (99449) provided on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with accessories (E02300, E1028, E2363, K0861).
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says the documentation shows the power wheelchair is for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with accessories (E02300, E1028, E2363, K0861).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and the enrollee is a good candidate for it. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not shown that Vertiflex is helpful for the enrollee's condition.
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 Vertiflex. 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 the safety and efficacy of this device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for drug administration services provided by an opted-out practitioner on November 12, 2020.
You asked the Plan to pay for drug administration services. You say that you were told these services were covered and would have found another provider if you were instructed to. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for drug administration services provided by an opted-out practitioner on November 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee had significant relief from this drug in the past. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Euflexxa. Our reviewer says that the requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovis before they will approve the requested drug. The documentation does not support that the enrollee has tried Orthovisc and Monovisc, or that these drugs would likely be less effective or have adverse effects for the enrollee 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide intermittent limb compression device and appliances.
You asked the Plan to provide intermittent limb compression device (E0652) and appliances (E0667). You say that the enrollee failed to respond to therapy over four weeks with using a non-segmented compression device. The Plan denied your request. The Plan says the requested service is not reasonable and medically necessary for the enrollee's condition.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide intermittent limb compression device (E0652) and appliances (E0667). Our reviewer says that an intermittent limb compression device and appliances are not medically necessary. Our physician reviewer found per CMS guidelines listed in LCD 33829 the member does not have the unique characteristics as outlined in the criteria for coverage. The review has determined that the pneumatic compressor and appliances are not medically reasonable or necessary. The enrollee does not meet criteria for the pneumatic compressor and appliances.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device (E0652) and appliances (E0667) have not been met. Therefore, we decided that the Plan does not have to provide intermittent limb compression device and appliances.