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

We decided that the Plan does not have to pay for the full-length bed rails (E0310) non-covered item (A9270)
purchased July 12, 2021, from an out-of-network provider.

You asked the Plan to pay for the bed rails. You say that you were told that if your doctor writes an
prescription, it would be covered. The items purchased were necessary. The Plan denied your request. The Plan
says this is a self-help item and is not covered by Medicare.

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 pay for the full-length bed rails (E0310) non-covered item (A9270)
purchased July 12, 2021, from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the vein ablation procedure to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the vein ablation procedure. You say that you are requesting approval for this procedure because your condition is getting worse. The Plan denied your request. The Plan says the provider is 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 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 the vein ablation procedure to be provided by an out-of-network (OON) provider.
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 the enrollee clearly exceeds LTACH admission criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.  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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan
denied your request. The Plan says SNF 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 SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled
services are not shown to be required to establish a maintenance program or to prevent deterioration of the
enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care
(ex. home, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair.

You asked the Plan to pre-approve the connection. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 connection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed your medical need. You do not require non-proportional input devices (e.g., sip and puff, head array, etc.). You do not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. You have two power options on the approved wheelchair but your upper extremity function with independence in eating supports that you can control any power options through 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 connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stent in groin artery (37221) to be provided by an OON provider.  You asked the Plan to pre-approve the insertion of stent in groin artery. You say that it is medically necessary for an out-of-network provider to treat your condition. The Plan denied your request. The Plan says they have in-network providers that are available to provide the medical care you need.  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 the insertion of stent in groin artery (37221) to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services required can be safely received in a different setting, for example - home with home health, in residential care, or home with close follow-up with the doctor.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: 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. The Plan denied your request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting 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 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. Our reviewer found that the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer also found that 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee has completed her acute care course of treatment and is stable for transfer to the LTACH, which is the next appropriate level of care. The Plan denied your request. The Plan says this request for approval of an admission to an LTACH does not meet the requirements for approval.  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 the enrollee is receiving appropriate care at the present acute care hospital.   The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our reviewer found that there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adcetris, Opdivo, and Zoledronic Acid.

You asked the Plan to pre-approve Adcetris, Opdivo, and Zoledronic Acid. You say that the medications 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 Adcetris, Opdivo, and Zoledronic Acid. Our reviewer says that the medications are not medically necessary. Our physician reviewer found the review has determined that the documentation support that the Adcetris (Brentuximab vedotin) with Opdivo (Nivolumab) and Zoledronic Acid is not medically reasonable and necessary for the enrollee. The documentation does not support that the Adcetris (Brentuximab vedotin) with Opdivo (Nivolumab) and Zoledronic Acid is safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Adcetris, Opdivo, and Zoledronic Acid have not been met. Therefore, we decided that the Plan does not have to pre-approve Adcetris, Opdivo, and Zoledronic Acid.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided from March 31, 2021, to May 26, 2021.  You asked the Plan to pay for the diagnostic services. You say that this service should be covered. The Plan denied your request. The Plan says the ultrasonic guidance for needle placement for a trigger point injection is considered experimental or investigational. The Plan also says that this service is not covered.  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 pay for the diagnostic services. Our reviewer says that the ultrasonic guidance for needle placement is not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate unique clinical characteristics that would require ultrasound guidance. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the reviewer found that the elements of the coverage criteria are not satisfied.  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 diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided from March 31, 2021, to May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on August 30, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that the hospital insisted that you should be transported to another facility by ambulance to treat your condition. You also say that you were told after you got the bill that the claim was billed with an incorrect modifier. The Plan denied your request. The Plan says these services were not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 pay for the ground mileage and non-emergency ambulance transportation. Our reviewer says that the documentation does not support that the ambulance transport on August 30, 2021 was medically reasonable and necessary. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for you. Our reviewer found that the documentation does not support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on August 30, 2021. Our physician reviewer also found that other means of transport would have been more appropriate.

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 ground mileage and non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on August 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on November 2, 2020, through November 24, 2020.  You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 97530 is Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.  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 therapeutic activities. Our reviewer says that CPT code 97530 does not meet criteria for billing or reimbursement consideration.  Our reviewer found the flow sheet does not specify what therapeutic activities were performed, and the time for each activity performed. For dates of service of November 2, 2020 and November 5, 2020, the provider billed 3 units, the flow sheet documents 35.  If 35 is the time for the therapeutic activities, 3 units are not supported.  15 minutes equals 1 unit.  When providing more than one unit of service, the initial and subsequent service must each total at least 15 minutes, and the last unit may count as a full unit of service if it includes at least 8 minutes of additional services. For the date of service of November 24, 2020, the provider billed 2 units, the flow sheet documents 20, if 20 is the time for the therapeutic activities, 2 units are not supported.  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 therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on November 2, 2020, through November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on July 19, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as your bill is usually only $10. 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). Your contract with the Plan clearly says that you must pay a $40 copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist visits.     You have been asked to pay a $40 copayment for a specialist office visit. The cost-sharing is higher this time because the rendering provider is an Orthopedic specialist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the pneumatic compression device.  You asked the Plan to pre-approve the pneumatic compression device. You say that you would like reconsideration because you are afraid that you will lose both of your legs if the compression device is not approved. The Plan denied your request. The Plan says there is no documentation supporting that you have completed 4 weeks of conservative treatment.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  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 pneumatic compression device. Our reviewer says that you do not meet Medicare criteria for coverage of the pneumatic compression device. Our physician reviewer found the documentation doesn't support that you have failed at least 4 weeks of conservative care with basic compression, activity, diet restrictions and elevation.  There is no follow-up documentation to support a failure of conservative 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 the pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device.