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

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 13, 2021.
You asked the Plan to pay for procedure code 62320. You say that this service was billed correctly and should be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the Plan has requested medical records from you multiple times to show that these services were appropriate. To date, you have not provided these records. Without this documentation, neither the Plan nor our organization can determine the appropriateness of these services.
Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 30, 2021.
You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the subcutaneous tissue debridement (11042), and the laboratory service (82948) rendered by the out-of-network (OON) provider on November 5, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 hospital outpatient clinic visit (G0463), the subcutaneous tissue debridement (11042), and the laboratory service (82948) rendered by the out-of-network (OON) provider on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Ostomy pouches (A5063 x180 units).
You asked the Plan to pre-approve the Ostomy pouches. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the amount of supplies requested is more than what is reasonable and 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 Ostomy pouches. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee is 91-year-old who undergoes daily colostomy care following treatment for colon cancer. The enrollee has a history of irritant dermatitis requiring more frequent changing of the ostomy pouch. The provider documents "No concerns. Stable, managed well by patient - does require bag change daily to prevent hygiene and infection concerns." The health plan must follow CMS rules and guidance per LCD L33828. The LCD allows coverage for A5063 x 20 units per month, or 120 units for 6 months, unless there is an explanation for use of a greater quantity of supplies. On appeal, the health plan will approve A5063 x 10 additional units per month (total of 60 units), bringing the total units approved to 180 for 6 months. The review has determined that the medical records provided meet the requirements listed in the LCD for Medicare coverage. 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 Ostomy pouches have been met. Therefore, we decided that the Plan has to pre-approve Ostomy pouches (A5063 x180 units).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair equipment (E1007, E1012, E2311,
E0955, E1028) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says these items are not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not show that the enrollee utilizes intermittent catheterization for bladder
management. There is no evidence that the enrollee needs a power seating system to manage tone or spasticity.
There is no documentation that he is unable to independently transfer from the wheelchair to bed or at a high
risk for pressure ulcers. Therefore, the request for the power tilt and power recline (E1007) exceeds the
enrollee's needs. The documentation does not reveal severe edema in the lower extremities or a cast or knee
brace therefore the E1012 elevating leg rests exceed the enrollee's medical need. As the power wheelchair does
not have two or more power seat functions the E2311 electronic connection is not medically necessary. The
documentation does not indicate that the enrollee has a manual tilt-in space, manual semi or fully reclining
back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline
power seating system. Therefore, the request for the (E0955) headrest is not medically necessary. The enrollee
additionally does not have indications for the E1028 hardware.
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 power wheelchair equipment (E1007, E1012, E2311, E0955, E1028) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 6, 
2021.
You asked the Plan to pay for procedure code 62320. You say that this service was billed correctly and should 
be paid. The Plan denied your request. The Plan says despite multiple requests, you have failed to provide 
medical records that would support the medical necessity of this service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. In this case, the Plan has requested medical records from you multiple times to show 
that these services were appropriate. To date, you have not provided these records. Without this 
documentation, neither the Plan nor our organization can determine the appropriateness of these services. 
Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of 
service September 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says the enrollee has not tried and failed Infed and Venofer.
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 Feraheme. Our physician reviewer found that the enrollee has iron deficiency anemia secondary to blood loss. The Plan requires a trial of Infed and Venofer before they will approve the requested drug. The case file does not contain documentation of trial and failure of Infed and Venofer. The documentation does not support that Infed and Venofer would likely be less effective or would likely 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 Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
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 self-administered drugs are not covered.
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.
Benefits for these services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR testing provided on October 7, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that urine PCR amplification techniques raise considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR testing provided on October 7, 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 you will receive better care at the IRF. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.
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. Our physician reviewer found that on review of the available records you are medically stable. You do not need
physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At your current level of function, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You need physical and occupation therapy in a lower intensity level as it is unlikely that you will make a significant functional progress in a reasonable period of time in an IRF. An IRF admission is not medically necessary based on lack of medical complexity, and lack of nursing needs. Documentation does not support the necessity for admission to an IRF. While you may benefit from physical and occupation therapy, your rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and to pay more for the periodic oral evaluation (D0120) provided on October 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodontal maintenance or pay more for the periodic oral evaluation. You say that you would like this claim to be reviewed and any reimbursement forwarded to you. The Plan denied your request. The Plan says these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that the periodontal maintenance is not a covered expense under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance (D4910) is not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for the periodic oral evaluation (D0120) plus the difference between the billed amount and allowed amount because the service was received OON. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and to pay more for the periodic oral evaluation (D0120) provided on October 19, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting.
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 that in this case, you were admitted with worsening shortness of breath requiring increased high flow oxygen in the setting of precious COVID-19 infection. The record indicates that you are improving but still requires acute care services. You continue to receive acute care services and these have not been denied. The medical record does not indicate that you require 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.
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 admission to a long-term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess (D7511) provided on 
September 22, 2021.
You asked the Plan to pay for the incision and drainage of abscess. You say that you feel these expenses should 
be covered under the dental plan due to the emergency situation and you would expect reimbursement. The 
Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan 
also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
incision and drainage of abscess (D7511) provided on September 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic esophagogastroduodenoscopy (43239) and a diagnostic colonoscopy (45384) provided on October 18, 2021.
You asked the Plan to waive the copayment for a diagnostic esophagogastroduodenoscopy and a diagnostic colonoscopy. You say that you were not informed of these charges for the procedure and the charges are not affordable at this time. The Plan denied your request. The Plan says you were 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 $300 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.
You have been asked to pay a $300 copayment for a diagnostic esophagogastroduodenoscopy and a diagnostic colonoscopy. A diagnostic esophagogastroduodenoscopy and a diagnostic colonoscopy fall 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 diagnostic esophagogastroduodenoscopy (43239) and a diagnostic colonoscopy (45384) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a joint injection and knee arthroscopy provided on April 20, 2021.
You asked the Plan to waive the deductible for the injection and arthroscopy. You say that the services were provided during an emergency stay and there was no indication at the time for any out of pocket costs. The Plan denied your request. The Plan says the correct amount was applied to your deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1500 deductible which applies to certain items and services. The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1500 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the injection and arthroscopy were received on April 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a joint injection and knee arthroscopy provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided on July 14, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided on July 14, 2021.