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

We decided that the Plan does not have to pay for intermittent limb compression device coded as E0651.
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee meets Medicare
criteria for the requested device. You respectfully ask for reversal of the denial determination. The Plan denied
your request. The Plan says records do not support meeting the medical necessity criteria.
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 pay for intermittent limb compression device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the review indicates that there is no specific clinical rationale for the
requested item. There is a lack of supportive documentation of measurements clinical. At a minimum, reassessments
conducted for a trial must include detailed measurements, obtained in the same manner and with
reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with
bilateral comparisons where appropriate. The review has determined that the medical records provided do not
meet the requirements listed in the LCD for Medicare coverage. The requested device is not medically
necessary for this enrollee at this time.
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 have not been met. Therefore, we decided
that the Plan does not have to pay for intermittent limb compression device coded as E0651.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 1,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that the services were not
necessary, and you were not the one that called the ambulance. 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 $440
copayment for ambulance services. You have been asked to pay a $440 copayment for ambulance services. Ambulance services fall within the
ambulance services 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 ambulance services
provided on June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport provided on April 21,
2021.
You asked the Plan to waive the copayment for ambulance transport. The Plan denied your request. The Plan
says you have been charged the correct cost sharing 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 $290
copayment per date of service for ambulance services. You have been asked to pay a $290 copayment for ambulance transport. Ambulance transport falls within the
Ambulance Services 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 ambulance transport
provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to a manual wheelchair.

You asked the Plan to pre-approve repairs to a manual wheelchair. You say that these repairs should be covered
by the Plan. The Plan denied your request. The Plan says you were approved for a power wheelchair in March
of this year. The Plan states Medicare does not cover duplicate equipment.

The Plan must follow Medicare rules. 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 file shows that you have a power wheelchair. This equipment serves the same
purpose as a manual wheelchair. Duplicate or spare equipment is not covered by the Plan or by Medicare.
Therefore, we decided that the Plan does not have to pre-approve repairs to a manual wheelchair.
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 you need intensive therapy to return to daily activities. The Plan denied your request. The Plan says you are not able to take part in therapy three hours a day.
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 physician reviewer found that you were admitted to the acute care hospital for viral meningitis. Your medical problems are stable.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.

You asked the Plan to pre-approve percutaneous vertebral augmentation (22513, 22514). You say that you are in extreme pain. The Plan denied your request. The Plan says your fracture was longer than six weeks ago.

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 percutaneous vertebral augmentation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the information provided for review did not demonstrate that the member had either an acute or subacute osteoporotic VCF. The member's symptoms had been present for a longer period of time and imaging did not show any acute or subacute changes (per radiology interpretation). This would ultimately not meet the Medicare criteria for coverage of this service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebral augmentation (22513, 22514) have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
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 you cannot get up. The Plan denied your request. The Plan says it is not likely the enrollee would be able to actively participate in 3 hours of therapy a day.
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 physician reviewer found that you were admitted to the acute care hospital for pneumonia. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper endoscopy and diagnostic colonoscopy you had at an outpatient hospital facility on May 20, 2021.
You asked the Plan to waive the copayment for the upper endoscopy and diagnostic colonoscopy. You say that this was a preventive test that should be covered without any copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $275 copayment for outpatient surgery in an outpatient hospital facility. Medical records from this date show that your doctor performed the upper endoscopy and diagnostic colonoscopy because you had left upper quadrant abdominal pain and bloating.
As a result, these were diagnostic and not preventive (screening) services. Because they were not screening services, the outpatient surgery copayment applies. 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 the upper endoscopy and diagnostic colonoscopy you had at an outpatient hospital facility on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the paravertebral facet joint injection procedure you had on March 17, 2021.
You asked the Plan to waive the copayment for the injection procedure. You say that you believe this copayment should be waived because this was a procedure and not a surgery. You stated that you did not go to the recovery room. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $350 copayment for outpatient procedures and services at an outpatient hospital facility or ambulatory surgery center.
You have been asked to pay a $350 copayment for the injection procedure. The injection procedure falls within the outpatient procedures and services at an outpatient hospital facility or ambulatory surgery center 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 the paravertebral facet joint injection procedure you had on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for refraction provided on June 15, 2021.

You asked the Plan to reimburse you for determination of refractive state (92015). You say that the refraction was not done for eyeglasses. The Plan denied your request. The Plan says the provider is out of network with the preferred vision vendor.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the preferred vendor. 

We looked at the file and the Plan's rules. The provider is out of network. Based on this information, we decided that the Plan's rules for coverage of determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to reimburse you for refraction provided on June 15, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you would not benefit from an intensive rehabilitation program.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis of the left foot and had left fifth ray amputation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diagnostic facet injections (CPT code(s): 64491, 64492, 64490).

You asked the Plan to pre-approve the injections. You say that the services are medically necessary due to high levels of pain. The Plan denied your request. The Plan says your request is not medically necessary because your records show you do not have at least 80% relief of primary (index) pain from your initial diagnostic facet joint injection.

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 injections. Our physician reviewer found the LCD requires 80% pain relief to be called a positive result. Therefore, the request is deemed 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the diagnostic facet injections (CPT code(s): 64491, 64492, 64490).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (CPT code G0299 X 6), for the enrollee.
You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
A doctor must certify the need for home health care services. 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 visits. Our physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The provided records report stable chronic medical conditions, stable vital signs and no wounds or medication changes or other diagnoses which require skilled nursing services. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits (CPT code G0299 X 6), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the magnetic resonance imaging (MRI) of the breast and the MultiHance injection you had on July 13, 2021.
You asked the Plan to waive the cost sharing for the MRI and MultiHance injection. You say that you believe that since these services were authorized, there would not be a cost share. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
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 $300 copayment for diagnostic imaging (including MRIs) and 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $300 copayment for the MRI and 20% coinsurance for the MultiHance injection. The MRI falls within the diagnostic imaging benefit category and the MultiHance injection falls in the Medicare Part B drug benefit category. This cost sharing applies even if these services were authorized. 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 cost sharing for the magnetic resonance imaging (MRI) of the breast and the MultiHance injection you had on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the podiatry visits you had on September 28, 2020, and March 1, 2021.
You asked the Plan to waive the copayments for the podiatry visits. You say that you had to have your nails cut and a diabetic foot care visit. You stated that your previous doctor never had a copayment for these services. The Plan denied your request. The Plan says you were charged these copayments correctly.
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 $40 copayment for podiatry visits. You have been asked to pay a $40 copayment for the podiatry visits. This copayment applies to all Medicare-covered podiatry services, including routine foot care. 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 copayments for the podiatry visits you had on September 28, 2020, and March 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services (CPT code G0299 X 2), for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee would continue to benefit from medically necessary skilled intervention in order to address the deficits affecting the enrollee's independence in performing the function, activities safely, as well as from an updated home exercise program (HEP), to reinforce safety in functional activities and, thereby, prevent falls/prevent rehospitalization. The Plan denied your request. The Plan says the records do not support the need for a skilled nurse to make more visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The provided medical records do not document a change in condition, unstable diagnosis or unstable physical examination finding, change in medication, wound or other diagnosis that requires skilled nursing services. 

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 home health skilled nursing services (CPT code G0299 X 2), for the enrollee.