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

We decided that the Plan does not have to pay for arthrocentesis (20611) provided on November 26, 2019.
You asked the Plan to pay for the arthrocentesis. 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 billed service.
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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. 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 arthrocentesis. Our reviewer says that CPT code 20611 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of an Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting being performed on November 26, 2019 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 arthrocentesis have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis (20611) provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Go-Go Elite Traveler 3 Wheel Scooter.
You asked the Plan to pre-approve the power operated vehicle. The Plan denied your request. The Plan says the records do not indicate that you meet the criteria for coverage.
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. The medical records provided state that you require the requested device for participating in community activities. 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 Go-Go Elite Traveler 3 Wheel Scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEliquis Tab 5mg.You asked the Plan to pre-approveEliquis Tab 5mg. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveEliquis Tab 5mg.Benefits for Eliquis Tab 5mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary, as you cannot go back to assisted living with a positive COVID-19 diagnosis. The Plan denied your request. The Plan says your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current skilled services after the effective date of 5/31/20. 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment beyond the last covered day. You do not have complex wound care, a need new enteral feedings or other SNF level need. Your functional level is near baseline does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment beyond the last covered date. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter, you do not require the necessary services on 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for closed treatment of a dislocation (21485) provided on November 4, 2019.
You asked the Plan to pay for the treatment. 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 service 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. In this case, the CPT Code Manual definition of code 21485 is closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent. 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 treatment. Our reviewer says that CPT code 21485 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include documentation of a Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent being performed on November 4, 2019, there for 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 treatment have not been met. Therefore, we decided that the Plan does not have to pay for closed treatment of a dislocation (21485) provided on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prodigy Talking Glucometer for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary due to the enrollee's vision, and not being able to read the glucose readings. The Plan denied your request. The Plan says the eye evaluation provides nothing about the enrollee's actual visual acuity.
The Plan must follow Medicare rules. Medicare rules say that a glucometer with voice feature is covered if the enrollee has a severe visual impairment. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found while the enrollee is noted to have diabetic ocular complications, the enrollee's visual acuity is not documented. As such, the documentation does not support that the use of a voice glucometer is medically necessary, reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Prodigy Talking Glucometer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation (99245) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office consultation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.
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 an office consultation (99245) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnbrel Sureclick.You asked the Plan to pre-approveEnbrel Sureclick. You say that the enrollee has tried and failed other drugs.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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-approveEnbrel Sureclick.Benefits for Enbrel Sureclickmaybe available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of pain related to osteoarthritis of the left knee. The diagnosis is confirmed on imaging and you failed a corticosteroid injection. The requested Orthovisc is not medically necessary, as you have not tried and failed three months of non-steroidal anti-inflammatory (NSAID) pain relief treatment. The Orthovisc is not safe and effective or medically necessary based on the submitted records.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 pre-approveOrthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty bathtub seat.
You asked the Plan to pre-approve the bath chair. You say that this is necessary for the enrollee. The Plan
denied your request. The Plan says Medicare does not cover this type of equipment as it is not medical in
nature.
The Plan must follow Medicare rules. Medicare rules say that shower/bath chairs are not covered because they
are not primarily medical in nature.
While a bath 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 heavy duty bathtub seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea percussion vest for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthe notes show pneumonia, therefore, this request is not medically necessary.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have recently had pneumonia in the setting of COPD and a recent CVA. There is no evidence that the enrollee has cystic fibrosis, post-polio syndrome, MS, muscular dystrophy or paralysis of the diaphragm. As such, the documentation does not support that a HFCWOD is medically necessary or reasonable.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea percussion vest for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia service provided on November 14, 2019.You asked the Plan to pay for the anesthesia service. You say that your back teeth were broken, and you received anesthesia to help with the extraction of your teeth. You also say that this should be covered because it was impacting your health and the procedure was recommended by your dentist.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the anesthesia service provided on November 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services from December 9, 2019 to December 31, 2019.You asked the Plan to pay for physical therapy services. You say that these services were needed.The Plan denied your request. The Plan says these services were not medically necessary.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 pay for physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy beyond what was approved by the health plan is not generally accepted as specific and effective therapy for the patient's condition. The patient has had extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The progress notes indicate the patient's therapy has been repetitive and did not require the ongoing skills of a professional therapist. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for physical therapy services from December 9, 2019 to December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network and out-of-country provider.
You asked the Plan to pre-approve the referral. You say that you out of the country, cannot travel due to COVID-19, and you need surgery on your hand. The Plan denied your request. The Plan says since this request is not urgent or emergent, this is considered not medically necessary to have the procedure done in another country.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The file shows that the diagnosis of atraumatic trigger finger on the 3rd digit of the right hand has been present for four months duration. There is no evidence that this is a urgent/emergent request. Based on this information, we decided that Medicare rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network and out-of-country provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom myoelectric upper extremity orthosis 'MyoPro Motion G' (L8702).
You asked the Plan to pre-approve the orthosis. You say that the device should be covered. The Plan denied your request. The Plan says the enrollee's condition did not meet the Medicare rules for approval of a custom upper arm prosthesis.
The Plan follows Medicare rules. Medicare rules say that for custom orthoses; additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. 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 orthosis. Our reviewer says that the request is determined not medically necessary. Our physician reviewer found the requested device has features that are determined deluxe and provide function which replaces rather than improves the function of the enrollee's arm. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the custom myoelectric upper extremity orthosis 'MyoPro Motion G' (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Minimed 670G insulin pump.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no order for a second pump.
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 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 record does not contain a physician order for a Minimed 670G insulin pump. The file shows that you have a Minimed 630G insulin pump. A Minimed 630G insulin pump serves the same purpose as a Minimed 670G insulin pump. Therefore, we decided that the Plan does not have to pre-approve a Minimed 670G insulin pump.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 services are medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 23, 2020 with headaches, altered mental status, and vomiting. Computed tomography (CT) of the head showed bilateral acute and chronic subdural hematoma. Speech therapy noted severe cognitive deficits and dysphagia on May 26, 2020. She requires maximal assist for bed mobility and transfers of two to three people. She is unable to ambulate. She is dependent for activities of daily living and participation is limited by fatigue. The records support the need for supervision by an acute physical medicine and rehabilitation physician and acute rehab nursing care. She will benefit from further speech, physical, and occupational therapy and requires an intensive cognitive rehab program at 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services (99239) provided on October 2, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the records do not support the service 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. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that the record does not support payment of CPT code 99239. Specifically, CPT code 99239 is a time based code. In order to bill CPT code 99239, the documentation must note that more than thirty minutes was spent providing services to the enrollee on the day of discharge. The progress note for October 2, 2019 does not indicate how much time was spent providing services to the enrollee. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services (99239) provided on October 2, 2019.