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

We decided that the Plan does not have to pre-approve a battery pack/cartridge for portable concentrator (E1356).
You asked the Plan to pre-approve a battery pack/cartridge for portable concentrator. You say that this is medically necessary as you cannot plug your battery into the outlet. The Plan denied your request. The Plan says durable medical equipment to be used outside of the home is not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a battery pack/cartridge for portable concentrator (E1356).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-preferred brand of diabetic testing supplies.
You asked the Plan to pre-approve the non-preferred brand of meter (E0607) and lancets (A4259). You say that the enrollee has used the requested brand for years. The Plan denied your request. The Plan says documentation was not provided that indicates the enrollee has limitations of use to the preferred brand product.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked the file and Medicare rules. You have not documented that the requested brand of test strips is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of meter and lancets have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-preferred brand of diabetic testing supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical insertion of a Vertiflex Superion device (22869).

You asked the Plan to pre-approve a Vertiflex Superion device. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says Vertiflex is experimental and investigational and does not meet the accepted standards of medical practice.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not 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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical insertion of a Vertiflex Superion device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic x-ray you received on May 5, 2021.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this is not covered when provided 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 the chiropractic x-ray you received on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed tomography (CT) services.
You asked the Plan to pre-approve the PET/CT scan. You say that the requested PET/CT is needed to provide the highest level of information in order to best plan for the enrollee and to help dictate care decision in order to continue to extend his life. The Plan denied your request. The Plan says the requested PET/CT is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PET/CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has a history of stage III non-small cell lung cancer. The enrollee has a fine needle aspiration of a questionable lesion that was negative and had an interval CT scan in May 2021 that was stable. The record also indicates that the enrollee had a previous PET/CT scan, his third post treatment, in February 2021, without evidence of recurrence. 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed tomography (CT) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-ray of the abdomen and the retroperitoneal ultrasound you had on April 28, 2021.

You asked the Plan to waive the copayments for the x-ray and ultrasound. You say that you do not understand why these services weren't covered as they were part of your annual doctor visit. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan says that for the ultrasound, the allowed amount for this service ($82.46) is less than your copayment obligation, so you are responsible for the full allowed amount for that service.

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 $15 copayment for x-rays and a $105 copayment for other diagnostic radiology services. 

You have been asked to pay a $15 copayment for the x-ray and a $105 copayment for ultrasound. According to your contract, separate cost sharing applies to these types of diagnostic tests even if they are performed during an annual routine physical exam or annual wellness visit. 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 x-ray of the abdomen and the retroperitoneal ultrasound you had on April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional non-emergency transportation trips.

You asked the Plan to pre-approve additional trips. You say that you have 2 appointments coming up this week. You also say that you need more trips. The Plan denied your request. The Plan says 24 one-way trips are covered per calendar year. The Plan also says that there are 0 trips remaining in 2021.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 4 additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full field electroretinography (ERG).
You asked the Plan to pre-approve the electroretinography. You say that you would like to appeal the denial of full field ERG for ocular hypertension due to the necessity to see if ocular hypertension is causing retinal stress. The Plan denied your request. The Plan says electroretinography is experimental or investigational because the clinical evidence does not show any value for treatment of high pressures in the eye.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electroretinography have not been met. Therefore, we decided that the Plan does not have to pre-approve full field electroretinography (ERG).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning provided on February 28, 2021.
You asked the Plan to pay for advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (99497). You say that you submitted medical documents substantiating the services performed. The Plan denied your request. The Plan says the medical records for this service is insufficient.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 99497 is not supported in the medical record. Specifically, the records support initial hospital care, there are no forms or mention of advance directives. Based on this information, we decided that Medicare rules for coverage of advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (99497) have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning provided on February 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0650).
You asked the Plan to pre-approve an intermittent limb compression device. You say that the equipment provider should not be punished without payment for a product provided based on the ordering physician's request. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of blood clots.
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. The file does not show that you have lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0650).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) and supplies for a 5th month.

You asked the Plan to pre-approve NPWT and supplies for a 5th month. You say that the wound has been slow to heal and that the requested continued therapy is medically necessary. The Plan denied your request. The Plan says the records show that the enrollee's wound has healed significantly, the wound vac has been used for 4 months, and there is no documentation as to why a switch to alternative treatments alone is not possible.

The Plan follows Medicare rules. Medicare rules say that a NPWT pump and supplies will be denied as not reasonable and necessary when 4 months have elapsed using a NPWT pump in the treatment of the most recent wound. 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 negative pressure wound therapy (NPWT) and supplies for a 5th month. Our reviewer says that the requested NPWT and supplies for a 5th month are not medically reasonable and necessary. Our physician reviewer found the enrollee has a wound (seroma) on her right hip, which is healing, but slowly. A wound vac has been used for 4 months. The medical records do not contain information which explains special circumstances necessitating an extended month of therapy, beyond the 4 months approved by the Plan. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of negative pressure wound therapy (NPWT) and supplies for a 5th month have not been met. Therefore, we decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) and supplies for a 5th month.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
April 19, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you did not receive urgent treatment
for your vaccine reaction, so you should not have to pay this 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 $90
copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of your
satisfaction with the services. 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 emergency room (ER)
visit you had on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Jazzy Air 2 power wheelchair (K0899).
You asked the Plan to pre-approve the wheelchair. You say that your current wheelchair has been discontinued, so it cannot be repaired. The Plan denied your request. The Plan says a power wheelchair with a seat elevator is a non-covered item.
The Plan must follow Medicare rules. Medicare rules say that K0899 represents a non-covered power wheelchair. Power wheelchairs that are coded with K0899 will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Jazzy Air 2 power wheelchair (K0899).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on April 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a drug test. You say that your lab performed all the tests that were ordered by the referring physician. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 items/services at issue in this appeal.
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a drug test provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablations.
You asked the Plan to pre-approve the lumbar facet joint radiofrequency ablations. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the requested repeat procedure is supported when documentation includes that the prior procedure provided 50% or more improvement of pain for at least six months or at least 50% improvement in ability to perform previously painful movements and activities of daily living (ADLs).
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 lumbar facet joint radiofrequency ablations. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not experience a minimum of a 50% improvement and the duration of relief was not for at least 6 months duration. 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 lumbar facet joint radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that this request is medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three endocrinology office visits to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve three endocrinology office visits to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).

You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you think you should be covered for this ice machine as the doctor ordered the machine to use after his total knee replacement surgery and they say using this machine helps with the recovery process. The Plan denied your request. The Plan says this item is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis the enrollee require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 31, 2021.

You asked the Plan to pay for the Guardant360 testing. 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 say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the Guardant360 testing is not supported in the medical record. Specifically, the services rendered would be considered a single procedural service, a single 5 gene panel, and it must be billed as such. These services were billed as unbundled services which is inaccurate. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 31, 2021.