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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services in a SNF setting.  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 services. Our physician reviewer found that you were treated at the acute care hospital for alcohol withdrawal, hyponatremia, urinary retention, encephalopathy, cellulitis with bacteremia and coronavirus infection. You are mostly bed bound, refusing to participate in out-of-bed activities and is mostly maximum assist for transfers and activities of daily living. There is no documentation that you require skilled nursing services of a skilled professional nurse to provide treatment. You do not require skilled therapy services due to reported refusals and inability to participate and ongoing delirium. Skilled services are not required on a daily basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Iclusig 30 mg tablet.  You asked the Plan to pre-approve Iclusig. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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-approve Iclusig 30 mg tablet.   Benefits for Iclusig may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve Accu-Chek Guide blood glucose (sugar) test strips.  You asked the Plan to pre-approve Accu-Chek Guide blood glucose (sugar) test strips. You say that the item is medically necessary. The Plan denied your request. The Plan says that this item is not the Plan's preferred brand.  The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers, as long as the conditions listed in the Medicare rules section of this letter are met.  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 Accu-Chek Guide blood glucose (sugar) test strips. Our reviewer says that you need this medical item. Our physician reviewer found this item will likely result in more consistent and accurate data with your current pump.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Accu-Chek Guide blood glucose (sugar) test strips have been met. Therefore, we decided that the Plan has to pre-approve Accu-Chek Guide blood glucose (sugar) test strips.  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: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the psychotherapy services (99213, 90833) provided on June 21, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that telehealth services are not covered when performed by an out-of-network provider as per the Evidence of Coverage.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied coverage based on specific language cited in the Evidence of Coverage. No Evidence of Coverage was provided to us. Without the Plan's Evidence of Coverage, we are unable to evaluate the Plan's denial and must find in favor of the requestor. Therefore, we decided that the Plan has to pay for the psychotherapy services (99213, 90833) provided on June 21, 2021.   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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have no daily skilled nursing or therapy needs.  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. Continued SNF services beyond February 11, 2022, was requested. 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 continued services. Our physician reviewer found that you were admitted to a skilled nursing facility after treatment in the hospital for atrial fibrillation and flutter. You are at a supervision assist level for walking using a rolling walker and transfers, and moderate assist for some activities of daily living. There is no documentation that you require the skills of a professional nurse or qualified therapist to provide medically necessary treatment. You do not require skilled services on a daily basis on an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient office visit (99202) and radiologic examination, spine, lumbosacral (72100) provided September 28, 2021.  You asked the Plan to pay for the office visit. You say that  The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99202) and radiologic examination, spine, lumbosacral (72100) provided September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the custom-fabricated oral device/appliance to reduce airway collapsibility (E0486) provided on April 18, 2021.  You asked the Plan to pay for the oral appliance. You say that the provider in this case is in network. You also say that the replacement appliance is medically necessary. The Plan denied your request. The Plan says that items or services you receive out of network are not covered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the file shows that the Plan denied this service based on the provider's network status. The file shows that the provider on the Evidence of Benefits does not match the provider listed on the submitted claim. Additionally, the provider listed on the submitted claim is listed on the Plan's website as a network provider. Therefore, we decided that the Plan has to pay for the custom-fabricated oral device/appliance to reduce airway collapsibility (E0486) provided on April 18, 2021.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to adjust the deductible applied for the transthoracic echocardiography (93351) provided on September 3, 2021.  You asked the Plan to adjust the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the service provided.    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 an annual deductible of $750. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services.   You have been asked to pay $425.15 for the diagnostic imaging test provided as you had not previously met the yearly deductible. The Plan contract states that you must pay an annual deductible of $750. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. This is the Plan's allowed amount for this service. 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 adjust the deductible applied for the transthoracic echocardiography (93351) provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system, push handles, stealth height adjustable joystick receiver, harness upgrade, expandable controller upgrade, and electronic connection between wheelchair controller and two or more power seating system motors.  You asked the Plan to pre-approve a power seat elevation system, push handles, stealth height adjustable joystick receiver, harness upgrade, expandable controller upgrade, and electronic connection between wheelchair controller and two or more power seating system motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a power seat elevation system is non-covered. Medicare rules also say that power wheelchair accessories are only covered for certain indications.  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 power seat elevation system, push handles, stealth height adjustable joystick receiver, harness upgrade, expandable controller upgrade, and electronic connection between wheelchair controller and two or more power seating system motors. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested accessories meet Medicare criteria for medically necessary. The power seat elevation feature and the push handles are statutorily non-covered as they are not primarily medical in nature. The expandable controller, harness and electronic connection do not meet criteria for coverage as provided records document that you have the ability to perform self-feeding and light grooming and hygiene with your left upper extremity thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. The stealth height adjustable joystick receiver is included in the expandable controller. Therefore, you do not meet criteria for the requested items.  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 power seat elevation system, push handles, stealth height adjustable joystick receiver, harness upgrade, expandable controller upgrade, and electronic connection between wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, push handles, stealth height adjustable joystick receiver, harness upgrade, expandable controller upgrade, and electronic connection between wheelchair controller and two or more power seating system motors.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the nuclear medicine scan.  You asked the Plan to pre-approve the nuclear medicine scan. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the requested nuclear medicine scan is not medically necessary.  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 the nuclear medicine scan. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there was insufficient explanation as to why the advanced imaging was needed in this clinical scenario following the pain pump refill.  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 nuclear medicine scan have been met. Therefore, we decided that the Plan does not have to pre-approve the nuclear medicine scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day Sensor kit.  You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet requirements for coverage.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you do not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 Freestyle Libre 14 day Sensor kit.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the muscle or fascia debridement (11043) provided on December 1, 2020.  You asked the Plan to pay for the muscle or fascia debridement. 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 11043 is debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less.  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 muscle or fascia debridement. Our reviewer says that CPT code 11043 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report describes debridement skin and subcutaneous tissue debridement, therefore this procedure cannot be confirmed as performed.  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 muscle or fascia debridement have not been met. Therefore, we decided that the Plan does not have to pay for the muscle or fascia debridement (11043) provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97811) and office or other outpatient visit (99215-25) provided from June 21, 2021, through August 12, 2021.
You asked the Plan to pay for the medical services. You say that you would like these services reprocessed based on the medical documentation. The Plan denied your request. The Plan says these various claims have not been billed in accordance with Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. Medicare rules say that modifier 25 is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. In this case, the MUE for CPT code 97811 is 2. The MAI value for this code is 3. You billed 3 units of this code, exceeding the MUE. Although the MAI indicates this may have been appropriate, no information was received that supports the medical necessity of exceeding the MUE. Furthermore, the office visits at issue were billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97811) and office or other outpatient visit (99215-25) provided from June 21, 2021, through August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 5, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis Tablet 5MG  You asked the Plan to pre-approve Eliquis Tablet 5MG. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.  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-approve Eliquis Tablet 5MG   Benefits for Eliquis Tablet 5MG may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an air purifier (E1399).  You asked the Plan to pre-approve an air purifier. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.        The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an air purifier (E1399).