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

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0670).

You asked the Plan to pay for a pneumatic compression device and appliance. You say that please see attached the RX, LMN and the clinical documentation to support medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0670).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided December 15, 2020 to December 23, 2020 billed with principal diagnosis N17.9 (Acute kidney failure, unspecified).  You asked the Plan to pay for the inpatient services billed with principal diagnosis N17.9. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with N17.9 defined as acute kidney failure, unspecified. 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 inpatient services billed with principal diagnosis N17.9. Our reviewer says that the documentation does not support that principal diagnosis billed. Our physician reviewer found the records describe the enrollee as having a decrease in urine output but in the setting of incontinence, treated with IV fluids and medication changes while monitoring kidney function. Creatinine was 1.31 mg/dL in the emergency department prior to admission and 1.10 mg/dL the next day. The enrollee's kidney function was not bad enough to meet criteria for acute kidney failure at the time of admission, and there was no other evidence provided to suggest this diagnosis was appropriate for this admission. Therefore, acute kidney failure is not supported by the documentation provided.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided December 15, 2020 to December 23, 2020 billed with principal diagnosis N17.9 (Acute kidney failure, unspecified).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive care services (CPT code (s): 86891, P9022, 99191, 99190-76 and 99190) provided to the enrollee on August 5, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are included in the inpatient payment.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. CPT code(s) 99190, 99190-76, 99191, 86891 and P9022, are included in the payment made to the facility where the enrollee was inpatient during this date of service. Therefore, we decided that the Plan does not have to pay for the comprehensive care services (CPT code (s): 86891, P9022, 99191, 99190-76 and 99190) provided to the enrollee on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 Receiver for an implantable glucose monitor.

You asked the Plan to pre-approve the monitor. You say that the enrollee needs that receiver for an implantable glucose monitor. The Plan denied your request. The Plan says the enrollee is taking medicines by mouth to treat the diabetes. The Plan states the request cannot be approved because Medicare does not cover implantable glucose monitors unless the enrollee is being treated with several doses of insulin daily or have an insulin pump.

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 monitor. Our physician reviewer found the documentation does not support that the enrollee is insulin-treated with multiple (three or more) daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. The coverage criteria, as established by L38617 have not been met in this case. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 Receiver for an implantable glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided from March 3, 2021, to March 9, 2021.  You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary and supported by the medical records. The Plan denied your request. The Plan says the billed principal diagnosis code is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis code A41.9 (sepsis unspecified organism). 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 inpatient hospital care. Our reviewer says that the billed principal diagnosis A41.9 is not supported by the medical record. Our physician reviewer found the physician documentation reflects patient had a platelet count of 385, total bilirubin of 0.2, international normalized ratio of 1.1 and lactic acid 1.7. The review has determined that the records did not support the billing of principal diagnosis A41.9.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from March 3, 2021, to March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve a power scooter. You say that the requested power scooter is medically necessary. The Plan denied your request. The Plan says you have not had a face-to-face evaluation.  The Plan must follow Medicare rules. Medicare rules say that the written order prior to delivery (WOPD)for the base item may only be written after the completion of the face-to-face encounter.  The file does not show that you have had a face-to-face encounter regarding the power scooter. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve SNF admission. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the member is functioning at a home care level and does not require daily skilled therapy to restore or maintain function.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is reasonably expected to benefit from skilled therapy, but services can be safely 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).  You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been proven more favorable than other treatments.  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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show it is safe and effective.  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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve SNF admission. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee requires daily skilled nursing or rehabilitation services that can only be provided in a SNF.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the member has failed several months of conservative approaches to treatment. You say that this treatment is considered safe and effective, and the necessary coverage should be provided. The Plan denied your request. The Plan says there are not enough studies to show Vertiflex Superion is safe and effective to treat back pain.
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 insertion of stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental. More research is needed to show safety and efficacy.
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 insertion of stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control.
You asked the Plan to pre-approve an attendant control. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in
addition to a beneficiary-operated drive control system, it will be denied as non-covered.
We looked at the file and Medicare rules. The requested item cannot be covered in addition to an enrollee
operated joystick. Based on this information, we decided that Medicare rules for coverage of an attendant
control have not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant
control.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225).  You asked the Plan to pre-approve the denture. You say that this service is necessary. The Plan denied your request. The Plan says the enrollee previously received a partial upper denture in October 2020, which was covered by the Plan at that time. Dentures may only be covered once every five years.  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 covers dentures and partial dentures for one set every five years.  Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the enrollee received a previous partial upper denture less than five years ago which was covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.

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 Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate the safety and efficacy of the device. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee has coverage for the rehabilitation that they are receiving. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care.  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 there were no skilled nursing needs. As of January 13, 2022, the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of January 13, 2022.  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 continued skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the disposable negative pressure wound therapy (NPWT) device.  You asked the Plan to pay for the disposable device. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the requested device is not a Medicare covered benefit.  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 disposable device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found disposable negative pressure wound therapy pumps are non-covered by Medicare.  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 disposable device have not been met. Therefore, we decided that the Plan does not have to pay for the disposable negative pressure wound therapy (NPWT) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the wipes (A9286).  You asked the Plan to pre-approve the wipes. You say that you would like reconsideration because these wipes are necessary due to the member's condition. The Plan denied your request. The Plan says the requested wipes are not a covered benefit.  The Plan must follow Medicare rules. The rules say that wipes will be denied as non-covered because they are not prosthetic devices nor are they required for the effective use of a prosthetic device.  We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage of the wipes have not been met. Specifically, wipes are not a covered benefit as they are not considered a prosthetic device and are needed for the effective use of a prosthetic device. Therefore, we decided that the Plan does not have to pre-approve the wipes (A9286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) provided on July 19, 2021.
You asked the Plan to pay for the root canal. You say that you do not understand why the cost of a root canal is
so high. The Plan denied your request. The Plan says there is an 80% coinsurance for services performed by a
specialist.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the root canals have not been met. Specifically, the file shows that you had a root canal performed
on the date on the date of service in this case. The record shows that the allowed amount for a root canal is
$1,400. $1,400 x 80% = $1,120. Therefore, we decided that the Plan does not have to pay for the root canal
(D3330) provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99203) provided on September 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that this service was rendered due to an emergency case. The Plan denied your request. The Plan says this service was not authorized nor was prior authorization obtained by the provider or facility. The Plan also says that they have confirmed that this was not an ambulance service, emergency and urgently needed, post stabilization care, nor dialysis while outside of the service area.  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 a specialist office visit (99203) provided on September 20, 2021, by an out-of-network (OON) provider.