Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 an inpatient skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet light cabinet.
You asked the Plan to pre-approve an ultraviolet light cabinet (E0694). You say that the enrollee has a skin condition and the ultraviolet light cabinet is recognized as a treatment. The Plan denied your request. The Plan says the enrollee's diagnosis is not a covered diagnosis for this device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ultraviolet light cabinet (E0694) have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light cabinet.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on January 14, 2020.
You asked the Plan to waive the copayment for the specialist office. You say that that according to your Evidence of Coverage, you do not pay for follow-ups after hospitalization. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records to support that the office visit was not a follow up visit to an observation stay. Therefore, we are unable to determine if the office visit qualifies for this benefit. Therefore, we decided that the Plan has to waive the copayment for a specialist office visit provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with tilt and recline.
You asked the Plan to pre-approve a Group 3 power wheelchair with tilt and recline. You say that the enrollee cannot complete a functional weight shift. The Plan denied your request. The Plan says the enrollee does not meet criteria for a special power wheelchair with tilt and recline.
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 a Group 3 power wheelchair with tilt and recline. Our reviewer says that the power wheelchair with tilt and recline is not medically necessary. Our physician reviewer found the documentation indicates that the enrollee has a mobility deficit that interferes with mobility related activities of daily living. The documentation does not reveal an in home assessment indicating the requested Group 3 wheelchair can safely be navigated within the home. The enrollee does not use intermittent catheterization for bladder management. The documentation does not reveal evidence of spasticity or increased tone. The March 18, 2020 seating and mobility evaluation does not clearly indicate whether the evaluation was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations of the patient's seating and positioning needs and no financial relationship with the supplier. The enrollee does not meet all the requirements for a Group 3 power wheelchair with power tilt and recline. 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 Group 3 power wheelchair with tilt and recline have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with tilt and recline.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant maintenance procedures provided on February 25, 2020.
You asked the Plan to pay for the implant maintenance procedures. You say that you received a routine cleaning which was not coded correctly because you have dentures. The Plan denied your request. The Plan says this implant service is not a covered benefit under your 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 implant maintenance procedures provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that your portable tanks do not allow you to finish errands or travel any distance. The Plan denied your request. The Plan says you are requesting a portable oxygen concentrator for use outside the home and travel.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The record shows that you have a stationary oxygen system with refillable portable tanks. Your portable oxygen system meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on January 7, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the test was not medically necessary for the enrollee's diagnosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the CPT Code Manual definition of code 87591 is Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique. 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 provided testing. Our physician says that the enrollee reported dysuria and pressure. Her physical examination was normal. A urinalysis collected was normal. The documentation does not support that the testing was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and the rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on December 30, 2019.
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 payment for this service is the responsibility of the facility to any vendor.
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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on December 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 3, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that due to the providers error you had to have the CT scan performed on separate days and you disagree with the additional copayment. 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 $50 copayment for CT scans. You have been asked to pay a $50 copayment for a CT scan. A CT scan falls 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 a CT scan provided on February 3, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says that you can receive the care you need at a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. You were medically stable with no evidence of need for supervision by a physical medicine and rehab physician or need for acute rehab nursing care. You may benefit from further physical therapy and an occupational therapy but does not require an intensive therapy program. You do not need a specialized rehab therapy expertise in an IRF and will not make significant functional gains in a predicted period of time in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 3, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because this claim was erroneously denied as inclusive to another procedure. The Plan denied your request. The Plan says that payment is not allowed because this claim contains non-anesthesia services submitted by and anesthesiologist.
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 looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was provided by a provider different than that of the anesthesia procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of impacted tooth - soft tissue (D7220).
You asked the Plan to pre-approve the dental services. You say that you need to have this tooth removed in order to get dentures. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth - soft tissue (D7220).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary. The Plan denied your request. The Plan says this has been approved under the enrollee's Part D benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Benefits for Retacrit may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the occupational therapy visits and the specialist office visits provided from January 9, 2020 to February 4, 2020.
You asked the Plan to waive the copayments for the occupational therapy visits and the specialist office visits. You say that you should not be charged a $30 copayment for the office visits in addition to the $25 copayment for the occupational therapy. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $25 copayment for each out-of-network Medicare-covered occupational therapy visit and a $30 copayment for services obtained from an out-of-network specialist or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). You have been asked to pay a $25 copayment for each of the occupational therapy visits and a $30 copayment for each of the specialist office visits. The occupational therapy visits fall within the "Outpatient Rehabilitation Services" benefit category. The specialist office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record shows that the strapping services are considered surgical services provided by a specialist practitioner.
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 copayments for the occupational therapy visits and the specialist office visits provided from January 9, 2020 to February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 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. 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 medical services provided on January 8, 2020 by an out of network (OON) provider.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on June 4, 2020 for treatment of increased pain and progressive weakness over the past few weeks. She needs moderate assist with ambulation and transfers. The progress note dated June 10, 2020 states she is full weight bearing with no fractures and pain is better controlled. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve water vapor thermal therapy.
You asked the Plan to pre-approve water vapor thermal therapy. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that water vapor thermal therapy is covered when the above criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve water vapor thermal therapy. Our reviewer says that the requested water vapor thermal therapy is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not meet all of the above LCD criteria for coverage of the requested Water Vapor Thermal Therapy. Specifically, prostate volume is less than 30 cc in size, IPSS score of &#8805; 13 not provided, and patient is not poor candidate for other surgical interventions for BPH due to underlying disease (e.g., cardiac disease, pulmonary disease, etc.), or at high risk of bleeding. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of water vapor thermal therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve water vapor thermal therapy.