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

We decided that the Plan does not have to pre-approve a replacement power wheelchair and related accessories.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says Medicare will not cover a replacement power wheelchair if it is less than five years old and the repair cost is less than the replacement cost.
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 file shows that your current power wheelchair is less than 5 years old. The records also show that the cost of repairs of your wheelchair is less than the cost to replace your wheelchair. Your current wheelchair serves the same purpose as the requested items. Therefore, we decided that the Plan does not have to pre-approve a replacement power wheelchair and related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 2 continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that you already received a glucose monitor. The Plan
denied your request. The Plan says you already have a CGM, so you do not meet criteria for coverage.
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.
Following Medicare coverage guidelines, specifically Medicare Ruling CMS-1682-R, the reader for a
continuous glucose monitor system is expected to last 3 years. Coverage for replacement is limited to once
every 3 years. The information received does not meet criteria because you received your current continuous
glucose monitor reader in January 2020. Therefore, this request will not be covered by your insurance.
The file shows that you already have a continuous glucose monitor. Therefore, we decided that the Plan does
not have to pre-approve Freestyle Libre 2 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts and a heel lift.
You asked the Plan to pre-approve the foot orthotics. You say that you have been told that this is the only option for your treatment to prevent/treat the issues you have related to your feet and legs. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts and a heel lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on December 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the hospital staff failed to obtain authorization and the doctor should not be penalized. You say the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 nursing facility care provided on December 7, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says you have used all 52 one-way trips for the
benefit year and additional trips will not be approved.
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 52 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. 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 routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant (D6010) for tooth # 22.
You asked the Plan to pre-approve the dental service. You say that you cannot afford to pay for this service.
You also say that you are on Social Security disability assistance. The Plan denied your request. The Plan says
implant is not listed as a covered service.
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 an
implant (D6010) for tooth # 22.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex device.
You asked the Plan to pre-approve a Coflex device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Coflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coflex device remains experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft in conjunction with periradicular surgery
(D3428), apicoectomy (D3425), retrograde filling (D3430), and biologic materials to aid in soft and osseous
tissue regeneration (D4265).
You asked the Plan to pre-approve the bone graft, apicoectomy, retrograde filling, and biologic materials. You
say that you need these procedures. The Plan denied your request. The Plan says these services are 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 pre-approve a
bone graft in conjunction with periradicular surgery (D3428), apicoectomy (D3425), retrograde filling
(D3430), and biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH services to regain maximum prior level of functioning and continue multi-disciplinary approach to care. The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the progress notes show that the patient appears to be improving but requires additional short-term acute care services which can be safely administered at the current facility until a lower level of care is appropriate. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already covered and available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered soon when treatment has completed.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x4).
You asked the Plan to pre-approve gingival irrigation. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the service at issue 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 gingival irrigation (D4921 x4).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Intracept Procedure remains experimental for back pain treatment. More research is needed to show safety and efficacy of the Intracept Procedure. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two precision attachments (D5862 x2) and complete mandibular overdenture (D5865).
You asked the Plan to pre-approve the precision attachments and complete mandibular overdenture. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services are 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 pre-approve two precision attachments (D5862 x2) and complete mandibular overdenture (D5865).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 31, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this should be covered. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.
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 record shows that the service at issue was provided by a therapist assistant in the home health or hospice 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 August 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the non-emergency transport (A0428) provided on November 11, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee's diagnosis is not related to hospice. You say that the services provided were not related to hospice care. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the non-emergency transport (A0428) provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide oral medical nutrition.
You asked the Plan to provide oral medical nutrition. You say that because of a medical condition the enrollee
needs these supplements. The Plan denied your request. The Plan says S codes are not valid for Medicare
purposes, Medicare uses another code for reporting of, and payment for, these services.
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 S9433 is Medical food nutritionally complete,
administered orally, providing 100% of nutritional intake, and the CPT Code Manual definition of code S9435
is Medical foods for inborn errors of metabolism.
We find that Medicare does not cover these S codes. Since these codes are not covered by Medicare they
cannot be approved. Based on this information, we decided that Medicare rules for coverage of oral medical
nutrition have not been met. Therefore, we decided that the Plan does not have to provide oral medical
nutrition.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 to you by an out-of-network provider on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX procedure.
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. The rules say that procedure code 43284 is noncovered. We looked at the file and Medicare rules. The requested service is a LINX procedure described by procedure code 43284. This code is denied by Medicare as noncovered. Therefore, we decided that the Plan does not have to pre-approve a LINX procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve IRF admission.
You asked the Plan to pre-approve the IRF admission. You say that you would like reconsideration because the member's needs will not be met in a lower level of care. The Plan denied your request. The Plan says that the records do not show that the member meets Medicare coverage criteria for the IRF admission.
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. Specifically, the record clearly indicates that the Plan reviewed medical records to inform their denial. These medical records were not included in the file. We requested these records and did not receive a response. It is the burden of the Health Plan to substantiate their denial with evidence. The denial has not been substantiated with evidence in this case so we must find in your favor Therefore, we decided that the Plan has to pre-approve IRF admission.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Maturity Obset Diabetes of the Young (MODY) panel.
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 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, a MODY panel, is being 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 pre-approve a Maturity Obset Diabetes of the Young (MODY) panel.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on January 29, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records do not show that the sample was taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on January 29, 2020.