Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the requested service. You say that the device will allow close monitoring of the enrollee's status. The Plan denied your request. The Plan says that an implantable congestive heart failure monitor is experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the requested service. Our physician reviewer found that the enrollee has Class III heart failure with preserved ejection fraction. She is on a high dose oral diuretic regimen with recent hospitalization for congestive heart failure (CHF). Management of her heart failure with standard medical therapy and relying on symptoms, weights and signs has not been effective in keeping her with minimal symptoms and has resulted in acute hospitalization. Overdiuresis with acute renal insufficiency has also occurred as her fluid status from physical exam is difficult to ascertain. Her lung disease also contributes to her symptoms, making precise management of volume status especially difficult, but also critical. CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex regimens to optimize fluid status. Given the severe symptoms of recurrent CHF which appear very sensitive to volume loading conditions, the complexity of the medical regimen, and the failure to prevent acute CHF hospitalization in this enrollee, use of the CardioMEMS device is reasonable. Clinical data, expert opinion, and approved FDA indications back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational for this indication and would meet the medical reasonableness and necessity criteria. 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 requested service have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS device.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatrist services provided on November 30, 2020 by an
out-of-network provider.

You asked the Plan to pay for the podiatrist services. You say that the provider was unaware authorization was
required. The Plan denied your request. The Plan says the service was not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the podiatrist services provided on November 30, 2020 by an
out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate maxillary denture (D5130) and immediate mandibular denture (D5140) provided on June 9, 2021.

You asked the Plan to pay for the immediate maxillary denture and immediate mandibular denture. You say that you were not told that the treating provider had to be in the Plan's dental network in order to be covered. You also say that you were only advised that you had to submit the claim information to the Plan in order for the enrollee to be reimbursed. The Plan denied your request. The Plan says dentures are not a covered benefit under the enrollee's plan.

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 immediate maxillary denture (D5130) and immediate mandibular denture (D5140) provided on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the chest (71046) rendered by the OON
provider on February 10, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the x-ray exam of the chest (71046) rendered by the OON provider on February 10,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 28, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
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 the denied codes is: CPT 36245: Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family CPT 37227:
Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed CPT 75710: Angiography, extremity, unilateral, radiological supervision and interpretation CPT 76942: Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure report does not document any of the denied services. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services provided to the enrollee on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110), provided on June 10, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the services should be covered. The Plan denied your request. The Plan says there's no coverage for dental services when services are rendered by an out-of-network provider.
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. Specifically, you received your care through an out-of-network provider. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110), provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says at this time, there is a lack of literature with true head to head comparisons to other standard 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of the left knee is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for personal transportation services provided by your neighbor 
on April 28, 2021. 
 
You asked the Plan to pay for personal transportation services provided by your neighbor. You say that the 
Plan's transportation provider had an accident and informed you that another driver would pick you up, but the 
wait time would be 1.5 hours, so you asked your neighbor to take you to your surgery appointment. The Plan 
denied your request. The Plan says personal transportation services are not a covered benefit. Additionally, no 
proof of payment was submitted with the request showing the appellant paid out of pocket in the amount of 
$500. 

Medicare does not cover transport in a vehicle that is not an ambulance.  
 
We looked at your request, the records in the case file, and the rules. The Plan's routine transportation benefit 
is limited to transportation with the Plan's contracted providers. Based on this information, we decided that the 
Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does 
not have to pay for personal transportation services provided by your neighbor on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 

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 necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on March 11, 2021.

You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional component/technical component indicator of 3, which means this code is a technical component only and should be reported in a hospital setting. The documentation shows that the enrollee was in an outpatient hospital facility setting. This means that rules for payment for this claim has not been met. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar injection services provided on May 12, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee was unable to have the procedure
without sedation. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We find that CPT code 62323 was billed with code 01936. This code pair has a modifier indicator of 1, which
means that the code may be eligible for payment if a modifier is appropriately appended. In this case, the claim
provided does not show the code at issue was billed with an appropriate modifier. 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 lumbar injection services provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the motorized scooter and accessories provided on June 2, 2021.
You asked the Plan to pre-approve the motorized scooter and accessories. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no documentation in the medical records provided that states that your mobility limitations cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 motorized scooter and accessories. Our reviewer says that the documentation did not include a face to face visit with a healthcare provider before the DME was delivered to support medical necessity for a power chair. Our physician reviewer found without this documentation, we are unable to determine if Medicare coverage criteria have been met. 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 motorized scooter and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the motorized scooter and accessories provided on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF.

Specifically, you do not show that you are able to perform fifteen hours per week of rehabilitative services. Your care 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 pay for the services (97014) provided on February 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code 97014 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97014) provided on February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography provided on May 25, 2021.
You asked the Plan to pay for the imaging services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not 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. We find that CPT code 70544 was billed with CPT code 70551. The CPT code 70544 may be eligible for payment when billed with this code pair. However, the provided claim did not indicate an appropriate modifier was billed. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an Inogen One G4 portable oxygen concentrator (E1392).)
You asked the Plan to pre-approve an Inogen One G4 unit. You say that the lighter portable oxygen concentrator is a medical necessity for you. The Plan denied your request. The Plan says that medical necessity rules for the requested item have not been met.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. 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 Inogen One G4 unit. Our reviewer says that the Inogen G4 portable oxygen concentrator, or an equivalent portable oxygen concentrator of similar weight, is medically necessary in this case.
Our physician reviewer found that you have the heavier Inogen G3 portable oxygen concentrator but are unable to use it for mobility in the home because of rheumatoid arthritis, lupus, and joint pain. The request for the lighter portable oxygen concentrator is medically reasonable. 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 Inogen One G4 unit have been met. Therefore, we decided that the Plan has to pre-approve an Inogen One G4 portable oxygen concentrator (E1392).)
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.