Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 the review has determined that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for chronic patients.

You asked the Plan to pre-approve the supplemental benefits. You say that you have chronic health conditions and would greatly benefit from these extra services. The Plan denied your request. The Plan says you do not have any of the eligible chronic conditions required to be approved for these services.

Medicare does not cover transportation for non-medical needs, provide an extra allowance for food or utilities, or provide access to any home repair or assistance services. However, the Plan offers a special supplemental benefit for chronic patients. For that reason, the Plan's coverage rules apply in this case. The Plan will provide the special supplemental benefits package for enrollee's who have one or more of the comorbid and medically complex conditions that are listed in the contract.

We looked at the file and Medicare rules. Your doctor indicated that you do have chronic conditions, however the diagnoses provided are not included in the Plan's list of conditions that are eligible for this benefits package. Based on this information, we decided that the Plan's rules for coverage of the supplemental benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for chronic patients.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1845) for the enrollee.

You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your request. The Plan says very little clinical information was received about the illness.

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 brace. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clinical documentation indicating instability; although the enrollee notes he has fallen several times due to the knee giving out. There has not been any recent injury or surgery to the knee. Detailed documentation is not evident regarding objective findings of instability. Furthermore, there are no corroborative imaging studies provided for review to demonstrate pathology of the knee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for knee brace (L1845) 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 brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace (L1845) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power-operated vehicle.

You asked the Plan to pre-approve a power-operated vehicle. You say that this request is medically necessary. The Plan denied your request. The Plan says this equipment is medically necessary.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power-operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4921).
You asked the Plan to pre-approve the services. You say that the dental plan does not cover enough. The Plan denied your request. The Plan says this is not a covered benefit.
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 pre-approve dental services (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy provided on February 17, 2021.
You asked the Plan to pay for the incomplete endodontic therapy. You say that the provider was unable to complete the root canal and advised you should get an extraction. The Plan denied your request. The Plan says this service is not covered.
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 incomplete endodontic therapy provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bi-level pressure respiratory assist device.

You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for the requested appliance.

The Plan must follow Medicare rules. Medicare rules say that respiratory assist devices are only covered under certain medical indications.

We looked at the file and Medicare rules. The records provided do not show that the enrollee has been consistently using the device. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a bi-level pressure respiratory assist device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for device evaluations provided from January 13, 2021, to March 24, 2021.

You asked the Plan to waive the copayments for device evaluations. You say that you wear a heart monitor and have never been charged in the past. 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 $30 copayment for diagnostic procedures and tests. 

You received device evaluations from January 13, 2021, to March 24, 2021, for a total of 6 services. Device evaluations are considered outpatient diagnostic tests. Therefore, you are responsible to pay a $30 copayment per each visit. However, you are only being asked to pay the total allowed amount of $152.02, which is less than the total copayment amount.

You have been asked to pay $152.02 for device evaluations. Device evaluations fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for device evaluations provided from January 13, 2021, to March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenetic testing provided on June 25, 2020.

You asked the Plan to pay for the pharmacogenetic testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

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 pharmacogenetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating that the pharmacogenomic testing ordered was due to any signs/symptoms of a drug reaction. There was no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug.

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 pharmacogenetic testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a sensor described by code A9276 is non-covered. We looked at the file and Medicare rules. The requested item is a sensor described by code A9276. This item is not covered by Medicare because it is for use with a non-therapeutic CGM. Therefore, we decided that the Plan does not have to pre-approve a sensor for a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that this is necessary for the enrollee to get in and out of his home. The Plan denied your request. The Plan says this item is not medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services, chest x-ray, CT of the thorax, ECG tracing, therapeutic intravenous infusion, injection of additional new drug or substance into vein, and injections provided on March 17, 2020.
You asked the Plan to pay for the laboratory services, chest x-ray, CT of the thorax, ECG tracing, therapeutic intravenous infusion, injection of additional new drug or substance into vein, and injections. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 laboratory services, chest x-ray, CT of the thorax, ECG tracing, therapeutic intravenous infusion, injection of additional new drug or substance into vein, and injections provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 13, 2020.

You asked the Plan to pay for the laboratory 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. 

We find that the laboratory services are not supported in the medical record. Specifically, laboratory services are not covered when a laboratory assays two or more genes in an enrollee in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services provided by an out-of-network provider on September 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest ultrasound examination of the heart provided on
January 25, 2021 by an OON provider.

You asked the Plan to pay for the chest ultrasound examination of the heart. You say that the treatment the
enrollee received was medically necessary. The Plan denied your request. The Plan says the service was
rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chest ultrasound examination of the heart provided on January 25, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for periodontal maintenance (D4910) provided on March 2, 2021.
You asked the Plan to pay an additional amount for periodontal maintenance. You say that you were told that the provider was in-network. The Plan denied your request. The Plan says all covered dental services rendered by an out-of-network provider will apply to the $500 benefit maximum.
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 periodontal maintenance have not been met. Specifically, services were rendered by an out-of-network provider. Covered dental services rendered by an out-of-network provider apply to your $500 benefit maximum. Therefore, we decided that the Plan does not have to pay an additional amount for periodontal maintenance (D4910) provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for an oral appliance.
You asked the Plan to pre-approve the referral. You say that there are only three providers that provide this service. The Plan denied your request. The Plan says the provider is contracted with the plan.
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 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 referral out-of-network for an oral appliance.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 25, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this should be covered as an in-network service. The Plan denied your request. The Plan says this was not billed correctly.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 25, 2020.
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 the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says home modifications cannot be made; therefore, the typical environment does not support
the use of a scooter.

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 scooter. Our reviewer says that the
requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no
documentation of a mobility deficit that significantly impairs MRADLs in the home. There is no evidence that
that you would be unable to be helped by a walker, cane, or manual wheelchair.

You have normal strength, and there is no objective assessment of your attempts at using a manual wheelchair or walker with evidence of oxygen desaturation or inability to use these devices. There is no evidence that you can safely maneuver the requested device in the home or that it will significantly improve MRADL performance in the home. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), abutment supported retainer crown (D6070), retainer crown (D6751) and pontic (D6241) provided on November 23, 2020.

You asked the Plan to pay for the dental services. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says these services are not covered by your dental benefits.

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 does not cover fixed dental bridges.

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 detailed and extensive oral evaluation (D0160), abutment supported retainer crown (D6070), retainer crown (D6751) and pontic (D6241) provided on November 23, 2020.