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

 We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.  You asked the Plan to pre-approve a CPAP device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that a PAP replacement device is covered when specific criteria are met.  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 CPAP device. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the record indicates that you have obstructive sleep apnea. The plan states that a machine was provided in 2019. The record does not document that there has been loss, theft, or irreparable damage due to a specific incident. The record does not contain sufficient information to determination ta the coverage criteria are satisfied. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network oncologist.  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 services are available from network providers.  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 to an out-of-network oncologist.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a spinal surgery.  You asked the Plan to pre-approve a spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not document that the enrollee is not indicated for operative intervention at no more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal surgery.
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do 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 that there is no documentation provided indicating medical necessity for LTACH. 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 he is currently receiving care. 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. 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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a sleep study (95800) provided on July 19, 2021.  You asked the Plan to pay for a sleep study. You say that a sleep study was medically necessary. The Plan denied your request. The Plan says a sleep study was not medically necessary.  The Plan follows Medicare rules. Medicare rules say that effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.  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 a sleep study. Our reviewer says that the sleep study was not medically necessary. Our physician reviewer found that the ENT exam were otherwise unremarkable and did not show any gross pathological evidence suggesting obstructive sleep apnea. There was no grasping and no nocturnal choking. There was no history of naps during the day. No issues staying awake while driving and no abnormal sleep behavior. Based on the Medicare NCD coverage criteria the medical necessity of sleep study using the dx code R06.83 is not justified.   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 sleep study have not been met. Therefore, we decided that the Plan does not have to pay for a sleep study (95800) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an endoskeletal system, below knee, alignable system.  You asked the Plan to pre-approve an endoskeletal system, below knee, alignable system. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 an endoskeletal system, below knee, alignable system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's medical need as the enrollee does not require 2 alignable systems and the documentation does not support that the enrollee has irreparable wear or damage or is unable to use the prior alignable system that was approved in 2020.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an endoskeletal system, below knee, alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal system, below knee, alignable system.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physician's services provided on  June 28, 2021.  You asked the Plan to waive the copayment for physician's services. The Plan denied your request. The Plan says you were seen for a follow up on your diagnosis of chalazion. The claim processed correctly according to the EOC.  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 $20 copayment for Vision Care, Medicare-covered visit.   You have been asked to pay a $20 copayment for physician's services. The physician's services falls within the Vision Care, Medicare-covered visit benefit category. 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 physician's services provided on June 28, 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 IRF admission should be covered. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  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 that the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 that the Plan does not have to pre-approve breast prosthesis services to be provided by an out-of-network provider.  You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve breast prosthesis services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endovenous ablation therapy (36478).  You asked the Plan to pre-approve endovenous ablation therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that treatments of the tributary veins will be considered medically necessary if the veins are greater than 4 millimeters (mm) in diameter.  We looked at the file and Medicare rules. The records show that the vein in question is not greater than 4 mm in diameter. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy (36478).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2021, through June 4, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says care could have been provided in an alternate setting, such as observation, emergency care or outpatient treatment.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2021, through  June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extractions (D7140) provided on February 3, 2021 and the lateral exostosis removal (D7471) and torus mandibularis removal (D7473) provided May 25, 2021.  You asked the Plan to pay for the extractions (D7140), lateral exostosis removal (D7471) and torus mandibularis removal (D7473). You say that insurance needs to reimburse you $1,656 for the medical services received. The Plan denied your request. The Plan says the services are not covered benefits.  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.    Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions (D7140) provided on February 3, 2021 and the lateral exostosis removal (D7471) and torus mandibularis removal (D7473) provided May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3000).  You asked the Plan to pre-approve foot orthotics. You say that you have trouble walking. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the orthotics are 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Partially Favorable

 We decided that the Plan has to waive the copayment for the diagnostic colonoscopy, flexible; with biopsy, single or multiple (45380) provided on August 5, 2021. We also decided that the Plan does not have to waive the copayment for the Esophagogastroduodenoscopy (EGD), flexible, transoral; with biopsy, single or multiple (43239)  provided on August 5, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the copayments have been applied correctly to the services provided.  We decided that the Plan has to waive the copayment for the diagnostic colonoscopy, flexible; with biopsy, single or multiple (45380) provided on August 5, 2021. The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The case file shows that the Plan did not provide medical records to our organization to determine if the service provided should have been billed as a diagnostic or preventative procedure. The Plan did not substantiate their determination. Therefore, we decided that the Plan has to waive the copayment for the diagnostic colonoscopy, flexible; with biopsy, single or multiple (45380) provided on August 5, 2021.   We also decided that the Plan does not have to waive the copayment for the EGD, flexible, transoral; with biopsy, single or multiple (43239) provided on August 5, 2021. 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 $400 copayment for outpatient surgery at an in-network ambulatory surgical center. The allowed amount for this service provided was $195.10, which is less than the applicable copayment. You are responsible to pay $195.10 for this service provided. Therefore, we decided that the Plan does not have to waive a copayment for the EGD, flexible, transoral; with biopsy, single or multiple (43239) provided on August 5, 2021.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the peritoneal abscess drainage provided during a cholecystectomy on July 15, 2020, billed with code 49020.  You asked the Plan to pay for the surgical services described by code 49020. You say that the billing provider was a co-surgeon during this procedure and should be reimbursed. The Plan denied your request. The Plan says that it was decided that payment could be made for code 47562 but that the services described by 49020 are typically provided during this primary procedure. As such, this service is inclusive to the main procedure and not separately payable.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a clear Medicare rule which would support that code 49020 is included in payment for code 47562. Code 49020 is defined as Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open. Code 47562 is defined as Laparoscopy, surgical; cholecystectomy. There is no National Correct Coding Initiative (NCCI) procedure-to-procedure edit for these two codes. Though the report does show that the abscess was drained during the cholecystectomy, not all cholecystectomies would require this as not all patients would have a peritoneal abscess found during the procedure. The operative report notes that this abscess was an incidental finding during the course of the gallbladder removal. This would mean that the payment rates for code 47562 would not include reimbursement for this additional service. As such, we find that the denial of payment for 49020 is not substantiated. Therefore, we decided that the Plan has to pay for the peritoneal abscess drainage provided during a cholecystectomy on July 15, 2020, billed with code 49020.   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 tub stool for the enrollee.  You asked the Plan to pre-approve the stool. You say that this is medically necessary due to the enrollee's diagnosis of cancer. The Plan denied your request. The Plan says this is considered a convenience item and 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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a tub stool for the enrollee.