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

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on July 8, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.  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) and segmental gradient pressure pneumatic appliance (E0673), provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on August 9, 2021.

You asked the Plan to pay for the pain management services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, there were no medical records provided for review to verify if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81201, 81317, 81432, 81295, and 81298) provided on June 14, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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. In this case, we have confirmed that code 81295 and 81298 are column II codes to column I code 81432. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.   The rules also say that laboratories shall not report multiple individual CPT codes describing the component test results. The file shows that the testing at issue (81201, 81317, and 81432) have component test results and were not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services (81201, 81317, 81432, 81295, and 81298) provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210), four two dimensional (2D) oral/facial photographic images (D0350 x4), and panoramic x-ray (D0330) provided on October 6, 2021.    You asked the Plan to pay for the complete series of intraoral x-rays, 2D oral/facial photographic images, and panoramic x-ray. You say that the dentist office personnel did not provide a detailed list of services to be performed in advance with their costs that you would be responsible for. You also say that you have not approved any services that the Plan would not have paid for. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.  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 complete series of intraoral x-rays (D0210), four two dimensional (2D) oral/facial photographic images (D0350 x4), and panoramic x-ray (D0330) provided on October 6, 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 would like reconsideration because the
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet
Medicare criteria for coverage of the IRF care.
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 with your comorbid conditions being 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. No acute or complex rehab nursing needs are
noted in the record. At the current functional status, you need Physical Therapy and Occupational Therapy but
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 will not make a significant functional progress in a reasonable
period of time in an IRF. You can be safely rehabilitated in a Skilled Nursing Facility.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of the CGM have not been met.  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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for urgently needed services provided on July
30, 2021, and August 8, 2021.
You asked the Plan to waive the copayments for urgently needed services. You say that you were told that you
would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for urgently needed services.
The medical records show that you received urgently needed services on July 30, 2021, and August 8, 2021.
Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $100.
You have been asked to pay the total copayment amount of $100 for urgently needed services. Urgently needed
services fall within the urgently needed services benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayments for urgently needed services provided on July 30, 2021, and August 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cranial hair prosthesis (wig).

You asked the Plan to pre-approve a wig. The Plan denied your request. The Plan says your condition of Lichen Planopilaris is not a diagnosis that qualifies for coverage of this item as the hair loss is not due to chemotherapy.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig except for members who experience hair loss due to treatment for cancer. Therefore, we decided that the Plan does not have to pre-approve a cranial hair prosthesis (wig).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.  You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.  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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of ongoing complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.  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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (PCD) (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on July 20, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism during or after surgery is a preventative service.  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 (PCD) (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lift chair provided on October 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a lift chair. You say that you paid out of pocket for the lift chair after wrangling for more than a month between your Plan and the primary care physician's office. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 lift chair provided on October 11, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from a SNF stay for his condition. The Plan denied your request. The Plan says daily skilled services are not required.

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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 78-year-old man with a medical history notable for heart disease, poorly-differentiated pancreatic adenocarcinoma, blood clots, anemia, and chronic kidney disease. The enrollee was admitted to the hospital on 2/10/22. It is documented that the enrollee has been limited by bilateral lower extremity weakness that had not improved while in rehab. On 2/16/22, the physical therapist documents that the enrollee was unable to stand fully erect primarily due to discomfort in his right ankle. 

The records do not show that the enrollee has any skilled nursing needs. The enrollee would benefit from ongoing skilled therapy, but this is not required on a daily basis in the inpatient 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics to treat flat feet.  You asked the Plan to pre-approve foot orthotics. You say that your chiropractor recommended orthotics for flat feet. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics to treat flat feet.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an ablation of malignant prostate tissue (55880) provided on August 5, 2021.

You asked the Plan to pay for an ablation of malignant prostate tissue. You say that, regardless of whether the provider at issue is a Medicare-approved doctor, he is a board-certified doctor and you should be reimbursed as for a non-network provider. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an ablation of malignant prostate tissue (55880) provided on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (22830) provided March 23, 2021.
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The Plan denied your request. The Plan says the code billed is included in the primary procedure and is not separately payable.
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 22830 is not supported in the medical record. Specifically, CPT 22830 is included in the primary procedure (22551). Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (22830) provided March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 19, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says clinical records have not been submitted.

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. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Group 1 standard power operated vehicle (K0800) provided on July 26, 2021.  You asked the Plan to pay for a Group 1 standard power operated vehicle. You say that the supplier at issue is the only supplier that will come to your residence if you need service or help. The Plan denied your request. The Plan says rules for payment have not been met because the supplier at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a Group 1 standard power operated vehicle (K0800) provided on July 26, 2021.