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

 We decided that the Plan does not have to pay for the services (75710) provided on May 14, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.  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 75710 is "Angiography, extremity, unilateral, radiological supervision and interpretation".  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 services. Our reviewer says that the use of code 75710 is not supported by the records provided. Our reviewer found that the operative report does not describe (per NCCI Policy Manual) an artery percutaneously punctured with a needle and guidewire is fed to the point of study.  A catheter is threaded over the guidewire until it reaches point of study, and the guidewire is removed. Contrast medium is injected through the catheter and a series of x-rays or fluorscopic images are taken, and vessels are evaluated for abnormalities.  Operative documents "Selective catheterization of the radial artery was performed and an arterialgram obtained". CPT code 75710 cannot be verified 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (75710) provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on July 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telehealth office services (CPT code 99204-95) provided to the enrollee on July 2, 2021, by an out-of-network provider.  You asked the Plan to pay for the telehealth office services. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered 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.  Telehealth services must be submitted to include the place of service equal to what it would have been had the service been furnished in person and append modifier 95 to indicate the service took place via telehealth. According to the service billed, the place of service listed was '02-Telehealth Provided Other than in Patient's Home'. Based on this information, we decided that Medicare rules for coverage of the telehealth office services have not been met. Therefore, we decided that the Plan does not have to pay for the telehealth office services (CPT code 99204-95) provided to the enrollee on July 2, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam therapy.  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 the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage T2c Gleason's grade 4+4 adenocarcinoma in five of 16 core biopsies taken on November 11, 2021. Abone scan, prostate-specific membrane antigen (PSMA) scan, and computed tomography (CT) scan did not reveal any metastatic lesions. There is insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, intensity modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. The proton beam therapy is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651, E0667).  You asked the Plan to pre-approve an intermittent limb compression device. You say that this equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 pre-approve an intermittent limb compression device. Our reviewer says that the requested intermittent limb compression device is not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the coverage criteria for the pneumatic compression device have been met. Records do not document marked hyperkeratosis with hyperplasia and hyperpigmentation or papillomatosis cutis lymphostatica or deformity of elephantiasis or skin breakdown with persisting lymphorrhea or detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology. In addition, the provided history in the clinical notes is inconsistent regarding whether leg elevation has improved the enrollee's symptoms.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0651, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) supply allowance billed with code K0553 for date of service April 9, 2021.  You asked the Plan to pay for the CGM supply allowance. The Plan denied your request. The Plan says the records provided do not support the item billed.  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. The rules also say that information must be submitted in order to determine whether payment is due and the amount of payment.   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 CGM supply allowance. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is not enough data to support the need for a CGM and related supplies. The records provided do not demonstrate how many shots of insulin and the regiment used from the note provided. The case file shows that all BGS levels are between 140-180, but actual log or readings are not provided. The data should be provided to document a need for and medical necessity of a CGM and related supplies.  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 CGM supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) supply allowance billed with code K0553 for date of service April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an emotional support dog (E1399).  

You asked the Plan to pre-approve an emotional support dog. You say that you need this dog. The Plan denied your request. The Plan says this is not a covered service.  

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 emotional support dog (E1399).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy.  You asked the Plan to pre-approve HBO therapy. You say that this treatment is medically necessary. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of the HBO therapy.  The Plan follows Medicare rules. The rules say that HBO therapy is covered for osteoradionecrosis as an adjunct to conventional treatment.  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 HBO therapy. Our reviewer says that HBO therapy is medically necessary. Our physician reviewer found that the requested service is covered for the treatment of the enrollee's condition as an adjunct to conventional treatment. The record indicates that the enrollee had squamous cell carcinoma of the oral cavity and underwent composite resection, neck dissection, and radiation. The record indicates that the enrollee has osteoradionecrosis. The elements of the coverage criteria are 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 HBO therapy have been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy.     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 pay for the skilled nursing services provided from August 1, 2021, to August 26, 2021.  You asked the Plan to pay for the skilled nursing services. You say that you have been waiting on this since August and no resolution has been made. The Plan denied your request. The Plan says no daily skilled nursing needs were noted. The Plan also says that your needs can be met in a lower level of care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility (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 pay for the skilled nursing services. Our reviewer says that you did not meet the Medicare criteria for SNF care. Our physician reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you did not require daily skilled nursing and/or skilled therapy 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 1, 2021, to August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from August 14, 2021 to August 22, 2021

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says authorization for post-stabilization care is denied.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility 8/14/2021 after the emergency room evaluation. The post-stabilization care services 8/14-8/22/2021 at the non-plan facility were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from August 14, 2021 to August 22, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nitro Euro style rollator walker, for the enrollee.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says if DME serves the same purpose as equipment already available to the enrollee, then it is not considered 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The enrollee does not have medical necessity for specific brand walker, Nitro Euro Style Rollator Walker. The plan provided a walker with seat on September 07, 2018, which is considered appropriate for the enrollee's medical condition; therefore, this is not covered. Therefore, we decided that the Plan does not have to pre-approve Nitro Euro style rollator walker, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 10, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve all lower extremity prostheses, flex-walk system or equal (CPT code L5981), all endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability (CPT code L5984), and addition to lower limb prosthesis, vertical shock reducing pylon feature (CPT code L5988).

You asked the Plan to pre-approve the items. You say that the enrollee does meet the requirements for the K3 level activity prosthetic foot and denying the enrollee from receiving the appropriate prosthetic foot would hinder their function as well as the enrollee's ability to continue to participate in their family's lives. The Plan denied your request. The Plan says that the records they have do not show why the requested advanced foot is needed and that is why these requested prosthetic parts are still denied.

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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pre-approve all lower extremity prostheses, flex-walk system or equal (CPT code L5981), all endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability (CPT code L5984), and addition to lower limb prosthesis, vertical shock reducing pylon feature (CPT code L5988).

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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for Part B drugs provided by on November 2, 2021.  

You asked the Plan to reduce the copayment for the Part B drugs. You say that you were told the coinsurance was only going to be $200. The Plan denied your request. The Plan says the proper coinsurance of 20% was quoted to the enrollee and the proper coinsurance was applied for this 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 20% coinsurance for each Medicare-covered Part B drug. The first allowed amount was $3,286.28 with a coinsurance of $657.26 ($3,286.28 total amount x 20% coinsurance). The second allowed amount was $1,813.12 with a coinsurance of $362.62 ($1,813.12 total amount x 20% coinsurance). The combined coinsurance amount was $1,019.88 ($657.26 coinsurance + $362.62 coinsurance).    

You have been asked to pay a 20% coinsurance for Part B drugs. The Part B drugs falls within Medicare Part B prescription drugs 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 reduce the copayment for Part B drugs provided by on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility or home with home health and home physical therapy.  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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for atrial fibrillation with rapid ventricular response and delirium tremens.  Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.