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

We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0652).

You asked the Plan to pay for the pneumatic compression device. You say that you would like reconsideration
because you cannot lift your leg and it is red and swollen. The Plan denied your request. The Plan says the
documentation does not support that you meet coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0652 used to treat lymphedema
extending onto the chest, trunk and/or abdomen that does not meet all of the requirements in the Medicare rules
section is not eligible for reimbursement.

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 the PCD. Our reviewer says that based on the
medical records provided there is no documentation that your condition failed to improve with a four-week trial
of a non-segmented compression device. Our physician reviewer found the records do not indicate that a 
non-segmented device has been tried.

We looked at this physician's review, the file and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided
that the Plan does not have to pay for the pneumatic compression device (PCD) (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided March 15, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary and reasonable in accordance with accepted standards of medical practice and the appropriate treatment of patients. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Interspinous device to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve the Vertiflex Interspinous device. You say that your doctor believes you are
a good candidate for this device. The Plan denied your request. The Plan says you did not request through a
network provider and you are not part of a clinical study involving the PILD.
Medicare rules say that CMS will cover this procedure if the member is enrolled in a CMS approved study. The
documentation does not support that you are enrolled in an approved clinical study that meets the criteria.
Medicare rules also 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 Vertiflex Interspinous device to be provided by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ablation procedure (64635, 64636).

You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region, no more than two
(2) radiofrequency sessions will be reimbursed per rolling 12 months.

We looked at the file and Medicare rules. The records show the enrollee previously had procedures on the same
spinal region on January 14 and January 21, 2021. No more than 2 sessions per region are covered per 12
months. Based on this information, we decided that Medicare rules for coverage of the ablation procedure have
not been met. Therefore, we decided that the Plan does not have to pre-approve an ablation procedure (64635,
64636).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips for routine transportation.
You asked the Plan to pre-approve additional trips for routine transportation. You say that you need additional
rides to your appointments because you do not have anyone to give you rides. The Plan denied your request.
The Plan says you have exceeded the number of covered trips for the year 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. The Plan provided documentation
showing that 24 trips have already been covered this year. Based on this information, we decided that you have
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the
Plan does not have to pre-approve additional trips for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre CGM and supplies (CPT code(s): K0553NU and K0554NU), for the enrollee.
You asked the Plan to pre-approve the CGM and supplies. You say that it is medically necessary based on type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee is not insulin-treated
with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion
(CSII) pump. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre CGM
and supplies (CPT code(s): K0553NU and K0554NU), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee's pain is disabling, affects their quality of life on a daily basis, and has been of long-term duration. The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting of chronic lumbar discogenic/vertebrogenic pain, lumbar degenerative disc disease, and severe thoracolumbar scoliosis have not been demonstrated in the peer-reviewed literature. The Plan states more research is needed to show safety and efficacy of the procedure.
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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure for bone graft. 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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following the elective right reverse total shoulder arthroplasty (CPT code 23472).
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 23472 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation you will require a greater than two (2) midnight stay. The Plan states if you experience any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 pre-approve 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 you appear to be stable and are not expected to require hospital services that would likely cross 2 midnights for this ambulatory procedure. 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 pre-approve the acute inpatient hospital care following the elective right reverse total shoulder arthroplasty (CPT code 23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lodging and meals.
You asked the Plan to pre-approve lodging and meals. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says there is no documentation of the enrollee obtaining an organ transplant. Medicare will not cover lodging and meals. There is no health plan supplemental benefit which would cover lodging and meals outside of an organ transplant.
The Plan must follow Medicare rules. Medicare will not cover lodging and meals. We looked at the file, the Plan's contract and Medicare rules. The file shows that you are requesting lodging and meals for non-organ transplant surgery services. Medicare will not cover lodging and meals. There is no
plan supplemental benefit which would cover lodging and meals outside of an organ transplant. Based on this information, we decided that Medicare rules for coverage of lodging and meals have not been met. Therefore, we decided that the Plan does not have to pre-approve lodging and meals.
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 have evidence of fatigue and endurance issues per current therapy notes. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy visits.

You asked the Plan to pre-approve the 8 additional physical therapy visits. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says the member does not meet coverage criteria for the additional physical therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 8 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the member has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the member's current condition or to prevent or slow further deterioration. 

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 8 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from April 14, 2021, through May 13, 2021.

You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment can be made for these services. The Plan denied your request. The Plan says the services rendered were custodial in nature and were correctly denied.

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs or skilled therapy needs beyond the date in question. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from April 14, 2021, through May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the abdomen provided on June 4, 2021 by
an out-of-network (OON) provider.

You asked the Plan to pay for the ultrasound. You say that in the physician's professional judgement, the
enrollee required the services provided. The Plan denied your request. The Plan says the treating provider is not
a network provider with the Plan. The Plan also says that the service was not urgent or emergent, nor was the
service approved in advance
.
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 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 ultrasound of the abdomen provided on June 4,
2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the two emergency-room (ER) visits you
had on May 26, 2021.
You asked the Plan to waive the copayment for the ER visits. You say that your doctor directed you to go to the
ER. You also said that you were told there would be no bill for these services. The Plan denied your request.
The Plan says you were charged these copayments correctly.
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 $50
copayment for emergency care.
Records show that you visited the ER twice on this date of service. You have been asked to pay a $50
copayment for each of the ER visits. These copayments apply regardless of the reason for the visits. 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 the two emergency-room (ER) visits you had on May 26,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on May 23, 2021.
You asked the Plan to pay for a supply allowance for a continuous glucose monitor. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors and related supplies have not been met.
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 assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation does not indicate that the enrollee has had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a supply allowance for a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on May 23, 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 you need assistance other than home health care. The Plan denied your request. The Plan says you do not need daily inpatient skilled services.

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 physician reviewer found that you were admitted to the acute care hospital for back surgery. You are medically stable without acute exacerbations of chronic medical problems. Although you do require further rehabilitation services, you do not need skilled nursing or therapy services on a daily 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an
ambulatory surgery center on May 19, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a screening
colonoscopy that should have no copayment. You also said that you believe the copayment for outpatient
surgery is $125. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $270
copayment for outpatient surgery (including diagnostic colonoscopies).
You have been asked to pay a $270 copayment for the diagnostic colonoscopy. The records show that this was
not performed as a screening colonoscopy. Rather, it was a diagnostic colonoscopy performed to evaluate you
for ulcerative proctitis and diarrhea. 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 the diagnostic
colonoscopy you had at an ambulatory surgery center on May 19, 2021.