Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block injection.

You asked the Plan to pre-approve genicular nerve block injection. You say that this requested procedure is
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage 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 genicular nerve block injection. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the enrollee is a 66-year-old female whose physician is appealing the
denial of a genicular nerve ablation with ultrasonic guidance needle for the patient's knee pain from arthritis.
The requested genicular nerve ablation of the knee is not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed body member. Currently there are
no higher quality studies demonstrating long-term efficacy and possible adverse effects of this procedure for
your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genicular nerve block injection have not been met. Therefore, we decided that
the Plan does not have to pre-approve genicular nerve block injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702).

You asked the Plan to pre-approve the powered upper extremity range of motion assist device. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is experimental for the intended use.

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 powered upper extremity range of motion assist device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of current medical literature shows that these service(s) do not have a proven benefit and are considered experimental/investigational. They are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature. 

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 powered upper extremity range of motion assist device have not been met. Therefore, we decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device services provided on
September 21, 2020.

You asked the Plan to pay for the services provided. You say that the equipment was issued to the enrollee for
use during their surgery. The Plan denied your request. The Plan says payment would have been included in the
facility payment.

The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services
to the beneficiary either directly or under arrangements made with outside providers.

We looked at the file and the rule. The billed claim shows that services were provided at an ambulatory
surgical center. This service was provided via arrangement of the facility. Payment for this service would have
been included under the facility claim. Payment to you for this service is the responsibility of the facility.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been
met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device services
provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308)
provided on May 18, 2021, by an OON provider.

You asked the Plan to pay for the nursing facility care. You say that you are requesting the Plan to review the
documents and process the claim towards payment. The Plan denied your request. The Plan says enrollee's
must receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.

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 subsequent nursing facility care, per day
(99308) provided on May 18, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction, electrical stimulation (97021) ultrasound (97035) provided April 14, 2021 to April 28, 2021.

You asked the Plan to pay for the chiropractic visits. You say that you were told you could go to any chiropractor that accepted the Plan. You were never made aware that you needed a referral from your doctor until 5 months after the fact. You would like to appeal what you owe in this instance. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction, electrical stimulation (97021) ultrasound (97035) provided April 14, 2021 to April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.

You asked the Plan to pre-approve a stair glide. You say that you are having difficulty going up and down the stairs. The Plan denied your request. The Plan says this item is not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).

You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested item.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 semi-electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no documentation provided indicating that the patient's condition requires position of the body in ways not feasible in an ordinary bed. and the patient's condition does not require special attachments that cannot be fixed and used on an ordinary bed.

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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the negative pressure wound therapy (NPWT) provided on
February 16, 2021, billed with code 97606.

You asked the Plan to pay for the NPWT as billed. You say that records support that payment should be made.
The Plan denied your request. The Plan says this payment is included in the payment made to the hospital for
inpatient care.

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 97606 is Negative pressure wound therapy (eg, vacuum
assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s),
wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50
square centimeters.

We find that CPT code 97606 is not supported in the medical record. Specifically, the note submitted for the
date of service makes no mention of any type of NPWT or any other wound care procedure. Based on this
information, we decided that Medicare rules for coverage of the NPWT as billed have not been met. Therefore,
we decided that the Plan does not have to pay for the negative pressure wound therapy (NPWT) provided on
February 16, 2021, billed with code 97606.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140), periapical x-ray (D0220), pontic (D6242) and retainer crown (D6750) provided on May 9, 2020, and June 9, 2020.

You asked the Plan to pay for the dental care. You say that this care was necessary as the result of an accident, and you feel they should be covered by your medical benefits as the reason for the care was medical and not your choice. The Plan denied your request. The Plan says Medicare does not pay for dental services, which are items and services involving the care, treatment, filling, removal or replacement of teeth or structures supporting the teeth. The services at issue are dental in nature. The Plan has agreed to pay for the extractions you received, but the other services are not covered by Medicare or by your plan.
Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140), periapical x-ray (D0220), pontic (D6242) and retainer crown (D6750) provided on May 9, 2020, and June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Shingrix vaccine provided on April 16, 2021.

You asked the Plan to pay for the Shingles vaccine. You say that the Plan told you the vaccine would be
covered. The Plan denied your request. The Plan says the vaccine is not covered under your Medicare Part B
benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles
vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Shingles
vaccine. Therefore, we decided that the Plan does not have to pay for Shingrix vaccine provided on April 16,
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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. 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.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (11720, G0127) provided April 29, 2021.

You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services billed were not separate from other services billed on a different claim on the same date of service.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, modifier 59 can only be used for these debridement procedures when the trimming and the debridement of the nails are performed on different nails or if the 2 procedures are performed at separate patient encounters. The provided records do not show that these criteria were met. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services (11720, G0127) provided April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on
December 23, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies
coverage for all cardiovascular risk assessment panels for patients with suspected or documented
cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary
cardiovascular screening testing provided on December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 4, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that you feel that the laboratory services should be included in your annual wellness exam. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $10 copayment for laboratory services. 

You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on March 2,
2021.

You asked the Plan to pay for the portable oxygen concentrator. You say that you would like this to be
reconsidered and covered by the Plan. The Plan denied your request. The Plan says that you did not obtain prior
authorization for this item.

The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily noncovered.
Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator
purchased on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care evaluation visit provided on March 25, 2021.

You asked the Plan to pay for critical care evaluation. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support a critical care visit of 30-74 minutes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the records submitted do not support a critical care evaluation service of 30 to 74 minutes in duration. Based on this information, we decided that Medicare rules for coverage of critical care evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a critical care evaluation visit provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this monitor is not reasonable and medically necessary.

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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 the Freestyle Libre therapeutic continuous glucose monitor.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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. 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.

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.