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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2310), and harness (E2313) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and related accessories. You say that the 
requested items should be approved. The Plan denied your request. The Plan says the power wheelchair was 
approved; however, the expandable controller is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller and related 
accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the provided records document that the enrollee has functional use 
of the right upper extremity including the hand with 4-/5 strength, and he is independent with personal hygiene, 
dressing and feeding thus indicating he has adequate right upper extremity strength and function to operate the 
wheelchairs power options with their own switches. 
 
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 expandable controller and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2310), and harness (E2313) for an approved power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a facedown recovery system provided on July 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the facedown recovery system. You say that it was imperative to use this recovery system in order to preserve your eyesight. The Plan denied your request. The Plan says the provider was out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a facedown recovery system provided on July 4, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on August 27, 2021 
and billed under code G0483. 
 
You asked the Plan to pay for code G0483. The Plan says while a portion of this claim was paid, code G0483 
cannot be paid as billed. The Plan states a National Correct Coding Initiatives (NCCI) Procedure to Procedure 
(PTP) edit exists for this code. The Plan states an appropriate NCCI modifier was not billed with this code.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary, the appropriate modifiers. In 
this case, this claim cannot be paid in full due to the omission of the required modifier. Medicare rules for 
coverage of code G0483 have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided to the enrollee on August 27, 2021 and billed under code G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transplant related lodging, meals and transportation expenses 
(S9975) provided May 13, 2021, to August 3, 2021. You asked the Plan to pay for the travel and lodging expenses. You say that you were in Denver, Colorado for 
evaluation and assessment as well as treatment. You are disputing the accommodations from 5/13/21 to 6/04/21 
and mileage as this is the treatment evaluation period approved. The Plan denied your request. The Plan says if 
the transplant evaluation/transplant listing denied, post care is denied then there is no travel and lodging 
reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that Original Medicare covers travel and lodging only 
for Medicare-approved organ transplants at a distant location that is farther away than the normal community 
pattern of care for transplant services. We looked at the file, and Medicare rules. The records show that an 
authorization was approved for the evaluation of the transplant, however, the transplant was denied. Based on 
this information, we decided that Medicare rules for coverage of the travel and lodging expenses have not been 
met. Therefore, we decided that the Plan does not have to pay for transplant related lodging, meals and 
transportation expenses (S9975) provided May 13, 2021, to August 3, 2021.
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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 received oral medications and had stable vital signs. Your lungs were clear. You were at a minimal to moderate assist level with functional mobility including gait. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve venous angioplasty and placement of stent.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity for coverage of the codes requested. This appears to be an error in coding. The enrollee is being treated for arterial occlusive disease, not venous. The health plan has already approved the request for arterial angioplasty with atherectomy. However, the additional codes requested (the subject of this review) were codes for venous angioplasty and venous stenting. As noted by the health plan, there is no evidence at all suggesting that venous angioplasty or venous stenting is even being considered. There is also no evidence that such procedures are indicated.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve venous angioplasty and placement of stent.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skin debridement services provided from 
March 10, 2021 to June 7, 2021. 
 
You asked the Plan to waive the copayment for the skin debridement services. You say that the services should 
be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment for Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 The enrollee has been asked to pay a $1,400 copayment for four skin debridement procedures ($350 x 4 = 
$1,400). Skin debridement services falls within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for skin debridement services provided from March 10, 2021 to June 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the patient is a 74-year-old female with ulcerative colitis with colostomy who
was admitted to the acute care hospital with partial small bowel obstructions requiring exploratory laparotomy,
bowel resections, and re-anastomoses. She was started on Total parenteral nutrition (TPN) and has been
receiving daily basic wound care. The patient appears to be improving overall, but requires short-term
additional acute care services that can safely be completed at the current facility until more stable. The patient
does not require services at the LTACH that are not already available at the current facility. There are no
services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be
considered when treatment has completed and when the patient is more stable.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the review has determined that the complexity of the patient's nursing, medical 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient require does not treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99211) provided on March 5, 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 that this service is not a covered benefit under 
your contractual policy or by Medicare.  
 
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 office visit (99211) provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), periodontal maintenance (D4910), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided September 29, 2021.
You asked the Plan to pay for the comprehensive oral exam, periodontal maintenance, bitewing x-rays and intraoral x-rays. You say that you were told this dentist was in your plan. The Plan denied your request. The Plan says periodontal maintenance is not covered under your benefits and the remaining services at issue are not covered when provided OON.
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. The Plan contracts says that
you are responsible for 100% of the cost of comprehensive oral exams, bitewing x-rays and intraoral x-rays when provided OON. We looked at the file and Medicare rules. In this case the services were provided out-of-network. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam, bitewing x-rays and intraoral x-rays have not been met Additionally, though the Plan offers dental benefits in excess of Medicare coverage, the periodontal maintenance is not among those covered services.. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), periodontal maintenance (D4910), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device with associated leg 
sleeves to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device with associated leg sleeves from an OON 
provider. You say that your health will continue to decline without the requested products. The Plan denied 
your request. The Plan says there are in-network providers within a reasonable distance from the enrollee's 
location who can provide the items being requested. The Plan says that there is no medical need to obtain these 
items from 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 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 pneumatic compression device with associated leg sleeves to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the voiding pressure studies (15797) provided on July 8, 
2021. You asked the Plan to pay for the voiding pressure studies. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 15797 was not billed with an 
appropriate primary procedure code. 
 
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 the 
voiding pressure studies is an add-on code and has not been billed with an appropriate primary procedure code. 
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 voiding pressure studies (15797) provided on July 8, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require at least 3 hours a day/5 days a week, or 15 hours over 7 consecutive days, of therapy services. 
While the enrollee may be able to participate in an intensive rehabilitation therapy program, the services could 
be provided at a lower 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 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: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for medical services provided to the enrollee on September 23, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says providers must document the dates the care was assumed and relinquished in the remarks/free text field or line 19 on the Centers for Medicare & Medicaid Services (CMS) HCFA 1500 claim form. If the provider doesn't submit both dates the claim will be denied.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate documentation. In this case this claim cannot be paid as billed due errors with the dates reported on the claim. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on September 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin injection provided in an outpatient setting from 
February 26, 2021, to March 1, 2021. 
 
You asked the Plan to pay for the self-administered drug. You say that this should be covered. The Plan denied 
your request. The Plan says the insulin injection provided in an outpatient setting is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the insulin injection is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin injection provided in 
an outpatient setting from February 26, 2021, to March 1, 2021.  
 
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
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 requested admission to a SNF is medically 
necessary The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria. 
 
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 received oral medications, had stable vital 
signs and were treated for pain. Your foley catheter was removed and you were treated for a UTI. You do not 
require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of 
service criteria for 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.