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

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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

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 dressings are non-covered under the surgical dressing
benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on January 12, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter/wheelchair, a stair lift, a shower bench, a raised toilet seat, and a scooter carrier for your car.

You asked the Plan to pre-approve the requested equipment. You say that you require these items. The Plan denied your request. The Plan says it was found that you do meet criteria for the requested manual wheelchair and seat lift. However, the criteria for a power operated vehicle are not met. Also, the other items requested are not considered medical in nature and cannot be covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also indicate that a power operated vehicle is covered only when a manual wheelchair cannot be used, and the enrollee can safely operate the vehicle. 

In this case, the power operated vehicle does not meet criteria since you are shown to be able to use a manual wheelchair, and there is limited information showing the vehicle can be safely used. The stair lift, shower bench, and raised toilet seat are not eligible for coverage as they are not medical in nature. The scooter carrier for the care does not serve a primarily medical purpose and is for use outside the home only. Therefore, we decided that the Plan does not have to pre-approve a power scooter/wheelchair, a stair lift, a shower bench, a raised toilet seat, and a scooter carrier for your car.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visits (99336) and the chronic care management service (99490) rendered by the out-of-network (OON) provider on April 12, 2021 and
April 26, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visits (99336) and the chronic care management service (99490) rendered by the out-of-network (OON) provider on April 12, 2021 and April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vasopneumatic device therapy procedure and subcutaneous injection provided on August 24, 2020.

You asked the Plan to pay for vasopneumatic device therapy procedure represented by codes 99211, 96372, and subcutaneous injection represented by codes J3490, J3415, J3411, and J1955. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no documentation a physical examination was performed or noting the presence of edema.

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. Vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service. The vasopneumatic device is to reduce edema or lymphedema, treatment of peripheral neuropathy with this device is not considered medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of vasopneumatic device therapy procedure represented by codes 99211, 96372, and subcutaneous injection represented by codes J3490, J3415, J3411, and J1955 have not been met. Therefore, we decided that the Plan does not have to pay for the vasopneumatic device therapy procedure and subcutaneous injection provided on August 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits

You asked the Plan to pre-approve the additional PT visits. You say that you have been receiving physical
therapy for lower back pain. So far you have had five visits. Your physical therapist believes you need eight
visits to meet the rehab goals that were set. The Plan denied your request. The Plan says the records do not
support that the enrollee meets the criteria for the requested PT visits.

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 the additional PT 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 based on review of the available records, the enrollee does
not meet CMS/LCD coverage criteria for the additional physical therapy visits when there is no change in pain,
ROM, or function. The documentation does not support coverage for additional physical therapy visits. The
enrollee should be able to do home exercises which were given to him.

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 additional PT visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 8 additional physical therapy (PT) visits
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve nasal/sinus endoscopy, surgical with dilation (31295, 30140, 31240, 31296).

You asked the Plan to pre-approve nasal/sinus endoscopy, surgical with dilation. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says that the service at issue is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve nasal/sinus endoscopy, surgical with dilation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been diagnosed with chronic sinusitis. He has failed maximal medical management including antibiotics, steroids, and sinus rinses. His computed tomography (CT) scan shows evidence of opacification and mucosal thickening in all of the sinuses. There was a concern for possible polyps on the CT scan, but the physical exam and the diagnosis do not mention polyps. Polyps of the nose is typically a clinical diagnosis, as it can be seen on anterior rhinoscopy or on nasal endoscopy. The CT scan is not diagnostic for nasal polyposis, especially when it states it might be mucus retention cysts. Allergy testing should not be considered a prerequisite for sinus surgery as allergic disease and sinus disease are 2 separate medical conditions and are treated separately. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nasal/sinus endoscopy, surgical with dilation have been met. Therefore, we decided that the Plan has to pre-approve nasal/sinus endoscopy, surgical with dilation (31295, 30140, 31240, 31296).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weight scale.

You asked the Plan to pre-approve a weight scale. You say that the item is medically necessary. The Plan denied your request. The Plan says the notes do not show that you are on dialysis treatment.

The Plan follows Medicare rules. Medicare rules say that ESRD facilities are responsible for supplies necessary for the effective performance of all modalities of home dialysis, for example, alcohol wipes, sterile drapes, gloves, telfa pads, bandages, etc. Necessary supplies could also include but are not limited to start-up durable supplies (whether or not they are part of a start-up kit) such as weight scales, sphygmomanometer, I.V. stand, and dialysate heaters; and consumable and disposable supplies such as dialysate, tubing, and gauze pads. Instruments and nonmedical supplies, such as scales, stopwatches, and blood pressure apparatus (this does not include automatic blood pressure monitoring devices such as those mentioned in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 3), are included in the ESRD PPS, regardless of whether provided separately or as part of a start-up kit. 

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 a weight scale. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no specific clinical rationale for the requested scale 

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 weight scale have not been met. Therefore, we decided that the Plan does not have to pre-approve a weight scale.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for the surgery provided on April
21, 2021.

You asked the Plan to pay for the surgical assistant services for the tendon sheath incision (26055). You say
that the primary surgeon considered the assistant surgeon necessary based on the medical necessity of the
surgery. The Plan denied your request. The Plan says that Medicare guidelines state that an assistant surgeon
may not be paid for this procedure.

The Plan must follow Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator
of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 26055. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure.

This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be
paid. Based on this information, we decided that Medicare rules for coverage of the surgical assistant services
for the tendon sheath incision (26055) have not been met. Therefore, we decided that the Plan does not have to
pay for surgical assistant services for the surgery provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) and radiologic examination, spine, lumbosacral (72100) provided April 5, 2021.

You asked the Plan to pay for the chiropractic services. You say that you have scoliosis and thought a chiropractor might help you. You were not aware that the Plan did not pay for x-rays for chiropractors. You did talk to customer service and was told that they would pay. The Plan denied your request. The Plan says these services are not covered when rendered 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 outpatient office visit (99202) and radiologic examination, spine, lumbosacral (72100) provided April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic screening provided on December 15, 2020.

You asked the Plan to pay for the services provided. You say that Medicare covers this test. The Plan denied your request. The Plan says experimental or investigational services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic screening provided on December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that you have no balance. You say that even though you can walk, you need 24-hour assistance with rehabilitation to get you back to independent living. The Plan denied your request. The Plan says care can be provided at a lower level.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. Therefore, the reviewer found that 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 admission have not been met. Specifically, the file shows that you do not require daily skilled services. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care visit provided on March 11, 2021.

You asked the Plan to pay for critical care visit. You say that you are appealing with records to support the
level of care billed. The Plan denied your request. The Plan says the denial of payment for this service is
correct, because the documentation submitted does not support a critical care visit of 30-74 minutes.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient, first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not support a
critical care visit of 30 to 74 minutes in duration. Based on this information, we decided that Medicare rules for
coverage of critical care visit have not been met. Therefore, we decided that the Plan does not have to pay for a
critical care visit provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the OON provider on
May 18, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by
the OON provider on May 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 3, 2020 to May 6, 2020.

You asked the Plan to pay for home health services. You say that you would like reconsideration because the final claim was submitted within the allowable timeframe. The Plan denied your request. The Plan says the claim recoupment was applied appropriately as the final claim was not received.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the documentation submitted does not include any evidence that the final claim was submitted within 120 days of the start of the episode or 60 days from the payment date of the RAP. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 3, 2020 to May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on March 4, 2021.

You asked the Plan to pay for foot orthotics (L3000, Q4037). You say that the orthotics were medically
necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

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.

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics
provided on March 4, 2021.