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

We decided that the Plan does not have to pre-approve the seat elevator (E2300) and phone holder (K0108).
You asked the Plan to pre-approve the seat elevator and phone holder. You say that you would like reconsideration because the seat elevator is required to facilitate transfers. The Plan denied your request. The Plan says the requested equipment is not primarily medical in nature.
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. A phone holder is available to the general public and would be helpful even to those who are not sick or injured. The seat elevator is specifically indicated in the LCA as not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve the seat elevator (E2300) and phone holder (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 15, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on February 15, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says a fixed dose of insulin twice per day is taken.

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. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation services coded as G0283 provided
March 26, 2021.

You asked the Plan to pay for the electrical stimulation services. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says the code has not been billed
with the appropriate therapy 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, the CPT Code Manual definition of code G0283 is electrical stimulation (unattended), to one or
more areas for indication(s) other than wound care, as part of a therapy plan of care.

We find that CPT code G0283 is not supported in the medical record. Specifically, CPT code G0283 is
considered a therapy code. This means that CPT code G0283 requires a therapy modifier of GN, GO or GP.
The claim shows that CPT code G0283 was not billed with a required therapy modifier. Based on this
information, we decided that Medicare rules for coverage of the electrical stimulation services have not been
met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation services coded as
G0283 provided March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1831) provided March 17, 2021.

You asked the Plan to pay for the orthosis. You say that the attached medical records clearly show medical
necessity from the ordering physician. The Plan denied your request. The Plan says this provided conducts
unsolicited outreach telephone calls to enrollees. Documentation indicated services are not necessary for
treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have
not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1831) provided
March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (21016) provided to the enrollee on
February 5, 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 the requested code is not substantiated by the clinical documentation.
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 21016 is "radical resection of soft tissue tumor (sarcoma),
of the face or scalp, for an excision 2 cm or greater."
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 services at issue in
this case were not supported by the medical records. Our reviewer found the record indicates that the enrollee
underwent a procedure. The operative note describes the resection of a cutaneous melanoma, not a soft tissue
tumor. The elements of the billed code are not satisfied.
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 surgical services (21016) provided to the enrollee on February 5, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on September 22, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is
not covered for screening purposes.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
This testing was ordered by an in-network physician for non-screening purposes. The file does not show that
the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is
considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided
on September 22, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain
coded as 70450 provided May 7, 2021.

You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was billed
without an appropriate 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 code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. 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 computed tomography (CT) scan of the head or brain coded as 70450
provided May 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional trips. You say that you need to go to dialysis 3 days a week. The
Plan denied your request. The Plan says additional trips are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 42 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used 42 trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that this is the only provider that uses cell technology to treat your type of condition. The Plan denied your request. The Plan says there are in-network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services needed to treat your condition. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond September 12, 2021.
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 continued services are not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF and received physical and occupational therapy. The physical therapy note dated September 6, 2021 states you need maximum assistance with rolling, sitting up, and lying down and modified assistance for toilet transfers, bed and chair transfers, and walking 10 feet. The records do not show that you have documented skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.

 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond September 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that the enrollee will need to progress to compression garments. The Plan denied your request. The Plan says the documentation does not support the need for a skilled therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The file shows that 10 additional physical therapy visits were requested. 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 additional services. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan.
The enrollee has had prior therapy. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. The enrollee has been compliant with compression maintenance and has used compression garments in the past. He can continue a home exercise program for hip strengthening/exercises. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain his current condition or to prevent or slow further 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that the enrollee is in pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there are currently no clinical indications for Vertiflex.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 20, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We looked at the file and Medicare rules. The file does not contain documentation of an established
relationship between the enrollee and the ordering provider. Without a record showing that this provider is
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revita, per sq cm (CPT code Q4180), for the enrollee.

You asked the Plan to pre-approve the skin graft. You say that the services are medically necessary. The Plan
denied your request. The Plan says your records do not indicate that the enrollee has failed attempts at
conservative wound therapy.

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 skin graft. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the records do not indicate that the enrollee has failed attempts at conservative wound therapy.
The review has determined that the items/services at issue in this case are not medically reasonable or
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 the skin graft have not been met. Therefore, we decided that the
Plan does not have to pre-approve Revita, per sq cm (CPT code Q4180), for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health aide services.

You asked the Plan to pre-approve the home health aide services.. You say that you are in a wheelchair and you cannot do anything for yourself. You state that you need help with everything. The Plan denied your request. The Plan says according to your primary care physician you do not require home health aide services.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our physician reviewer found the provided medical records document that you are not homebound and no documentation is provided that you are receiving any home health skilled nursing or therapy services. There is no documentation that the requested home health aide services meet the definition of reasonable and necessary per Medicare criteria.

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 home health aide services. have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a pneumatic compression
device (E0651, E0667, E0668).

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there are network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral out-of-network for a pneumatic compression device (E0651, E0667, E0668).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional service for single injection of allergen
(95115) provided on March 23, 2021, by an OON provider.
You asked the Plan to pay for the professional service for single injection of allergen. You say that you would
like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior
authorization was not obtained for these services rendered by an OON provider.
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 professional service for single injection of
allergen (95115) provided on March 23, 2021, by an OON provider.