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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do 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. Your high 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. You do 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 you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pay for the chest/mediastinal ultrasound interpretation provided on April 12, 2021.  You asked the Plan to pay for the ultrasound interpretation. You say that this code is payable in the emergency room setting and was medically necessary. The Plan denied your request. The Plan says that this interpretation was done in the hospital setting by a specialist that does not typically provide radiological interpretations in the hospital setting. This means it cannot be paid.  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. The Plan has not provided a valid denial rationale for the services at issue. It is noted that the Plan states that payment cannot be made because this interpretation was done by an emergency medicine physician which is not the specialty typically responsible for radiological interpretations in the hospital. While it may not be typical for this specialty to interpret an imaging study, the records clearly show that the ultrasound was performed by a student physician and was also reviewed by the billing emergency medicine physician. This was done emergently which would explain why this interpretation was not done by a radiologist as the information needed to guide care was needed in real time. There is also no evidence that any other claim for this interpretation was submitted or paid on this date of service. Based on this information, we find that the denial of payment for this service is not substantiated. Therefore, we decided that the Plan has to pay for the chest/mediastinal ultrasound interpretation provided on April 12, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on April 14, 2021 to June 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the treatment you received was medically necessary and more cost effective and safer than the alternative of surgery. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the outpatient office visit (99203) provided on April 14, 2021 to June 2, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.  You asked the Plan to pre-approve 7 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 7 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on May 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is responsible to obtain prior authorization for all of their patients, which should also cover for the medical treatments provided by the provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the domiciliary or rest home visit (99336) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the limited arterial duplex scan provided on June 29, 2021, billed with code 93976.  You asked the Plan to pay for the billed code 93976. You say that this was medically necessary imaging. The Plan denied your request. The Plan says this was not billed with the required modifier.  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 the billed code 93976 is a column II code to column I code 76856. 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. Therefore, we decided that the Plan does not have to pay for the interpretation of the limited arterial duplex scan provided on June 29, 2021, billed with code 93976.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99152) provided on April 22, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 99152 is a column II code to column I code 43239.     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. Therefore, we decided that the Plan does not have to pay for the services (99152) provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bag hooks (K0108), seat elevator (E2300), and electrical connection (E2311).  You asked the Plan to pre-approve bag hooks, seat elevator, and electrical connection. You say that the items are medically necessary. The Plan denied your request. The Plan says the bag hooks and seat elevator are not primarily medical in nature and the enrollee does not meet the criteria for the electrical connection.  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. Our reviewer says that the electrical connection is not medically necessary. Our physician reviewer found that the approved power wheelchair only has one approved power feature (power tilt). With only one approved power feature, there is no need to control two or more power features through the joystick. The enrollee is reported to have right upper extremity strength within functional limits.  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 bag hooks (K0108), seat elevator (E2300), and electrical connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on June 30, 2021.  You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says you exceeded the limit of the $240.00 maximum benefit every 24 months for eyewear.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every 24 months.  We looked at the file and the Plan's rules. The file shows that you used the eyewear benefit last on  November 12, 2020, exceeding the maximum benefit limit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for an emotional/behavioral assessment provided on July 21, 2021, by an out-of-network provider.  You asked the Plan to pay for an emotional/behavioral assessment. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.    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 an emotional/behavioral assessment provided on July 21, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an inpatient hospital endoscopy (74330) rendered on November 5, 2020.  You asked the Plan to waive the deductible for an inpatient hospital endoscopy. 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). The Plan contract says that there is a $198 deductible for all items and services except those specifically excluded by the Plan contract.   You have been asked to pay a $23.08 deductible for an endoscopy. Inpatient hospital endoscopies fall within the Inpatient Hospital Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible, which applies to an Inpatient Hospital 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 that had not been met at the time of the inpatient hospital magnetic resonance imaging rendered on November 4, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital endoscopy (74330) rendered on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xofigo.  You asked the Plan to pre-approve Xofigo. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Xofigo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xofigo have not been met. Therefore, we decided that the Plan does not have to pre-approve Xofigo.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is still considered investigational.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical management.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 15 occupational therapy visits.  You asked the Plan to pre-approve 15 occupational therapy visits. You say that you want to maintain optimal level of independence to remain residing in your own home safely. You say that you wish to gain strength, improve mobility and remain free of falls and fall related injuries. The Plan denied your request. The Plan says additional visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   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 15 occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of the limited available records, you do not meet the coverage criteria for the requested 15 occupational therapy visits.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 occupational therapy visits.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has pre-approve a positron emission tomography (PET) computed tomography (CT) scan from the skull to mid-thigh.  You asked the Plan pre-approve a PET/CT scan from the skull to mid-thigh. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.  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 pre-approve a PET/CT scan from the skull to mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found a PET/CT for initial evaluation after diagnosis of breast cancer is a covered benefit for staging. You have had bilateral mastectomies and a PET is a very reasonable and necessary option for your evaluation.  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 PET/CT scan from the skull to mid-thigh have been met. Therefore, we decided that the Plan has pre-approve a positron emission tomography (PET) computed tomography (CT) scan from the skull to mid-thigh.   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 the Plan does not have to pay for the seat lift chair and mechanism purchased on May 8, 2021.  You asked the Plan to pay for the seat lift chair and mechanism. You say that the Plan should pay for this lift chair. The Plan denied your request. The Plan says you did not have prior authorization to purchase this equipment out of network.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed are met. Medicare does not cover the upholstered chair sold with the mechanism. The Plan contract says that enrollees must use network providers and that durable medical equipment requires prior authorization. There were no medical records submitted by your physician to show you meet the required criteria for coverage. You did not follow your Plan contract rules when purchasing this equipment. Therefore, we decided that the Plan does not have to pay for the seat lift chair and mechanism purchased on May 8, 2021.