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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the services are medically necessary. The
Plan denied your request. The Plan says the enrollee does not require daily skilled services. The Plan also says
that the SNF admission is not medically necessary.
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 the SNF admission. Our reviewer says
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did
not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 17, 2020.
You asked the Plan to pay for this claim in full. You say that the Plan should pay this claim as it was for Covid 19 testing, which is covered by Medicare. The Plan denied your request. The Plan says while a portion of this claim was paid the remaining codes on the claim could not be verified as having been ordered by the physician listed on the claim. The codes denied are 80061, 81225, 81226 ,81227, 81230, 81231,81240, 81241, 81291,82306, 82728, 82977, 83036, 84439, 84443.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Providers must also submit medical records and appropriate physician orders for the services rendered. In this case, insufficient medical records and/or physician orders were submitted to support those services billed and denied by the Plan. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
You asked the Plan to pre-approve the ventilator. You say that medical documentations will show the need for a home ventilator to cease the visits to the emergency and in hospital stay or death. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare criteria for reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.
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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the need for the ventilator device. The records show that the enrollee was requiring settings available on a BiPAP machine with AVAPS adaptive-servo ventilation technology which would suggest this type of device would be more appropriate and the portable home mechanical ventilator not appropriate considering her needs. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on May 14, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $100 copayment for emergency care/in-network. 

You have been asked to pay a $100 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care/in-network 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 an emergency room visit provided by a participating provider on May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 26, 2021 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 physician services provided on January 26, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on August 29, 2020.
You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We find that CPT code 97110 is not supported in the record. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on August 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorper tab 10mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorper tab 10mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on April 6, 2021.

You asked the Plan to waive the copayment for vision care. You say that you requested a routine eye exam and feel that for this reason you should not be charged a 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 $45 copayment for vision care provided by a specialist and a $0 copayment for routine vision care. 

The medical records show that you received vision care beyond a routine eye exam on April 6, 2021. Therefore, you are responsible to pay the $45 copayment. 

You have been asked to pay a $45 copayment for vision care. Vision care falls within the vision care 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 vision care provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospitalist physician certification (G0180) provided on February 22, 2021, by an out of network (OON) provider.

You asked the Plan to pay for a hospitalist physician certification. You say that the doctor is a hospitalist and depends upon the hospital staff to verify eligibility and to obtain proper authorization from the patient's insurance. The Plan denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a hospitalist physician certification (G0180) provided on February 22, 2021, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve K3 lower limb prosthetic components.
You asked the Plan to pre-approve K3 lower limb prosthetic components. You say that your doctor has signed a detailed description stating that you are a K3 patient. The Plan denied your request. The Plan says the denial of authorization for these prosthetic components is corrects, because you require a power wheelchair which is inconsistent with K3 ambulatory function.
The Plan follows Medicare rules. Medicare rules state that determination of medical necessity for lower limb prosthetic components is based on the enrollee's potential functional abilities. 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 K3 lower limb prosthetic components. Our reviewer says that you do not meet the Medicare criteria for the requested K3 prosthetic components. Our physician reviewer found the records indicate that you require and use a power wheelchair for mobility. This is not consistent with a K3 ambulatory status and the requested K3 lower limb prosthetic components. Records do not document that you have the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of K3 lower limb prosthetic components have not been met. Therefore, we decided that the Plan does not have to pre-approve K3 lower limb prosthetic components.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive periodontal evaluation - new or established patient (CPT code D0180), bone replacement graft - retained natural tooth - first site in quadrant (CPT code D4263) and gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (CPT code D4241).

You asked the Plan to pre-approve the dental services. You say that you are suffering due to your condition and these services are important to keep your dental health and help you eat. The Plan denied your request. The Plan says the services are 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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve comprehensive periodontal evaluation - new or established patient (CPT code D0180), bone replacement graft - retained natural tooth - first site in quadrant (CPT code D4263) and gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (CPT code D4241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Aerochamber Plus spacer device.

You asked the Plan to pre-approve the Aerochamber Plus spacer device. You say that you would like reconsideration because you have trouble using your inhaler. The Plan denied your request. The Plan says the Aerochamber Plus spacer does not meet the definition of DME and is therefore not covered.

The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Aerochamber Plus spacer device have not been met. Specifically, The Medicare National Coverage Determinations (NCD) Manual indicates that this item is always non-covered. Therefore, we decided that the Plan does not have to pre-approve the Aerochamber Plus spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2310) and push handles (K0108) for a power wheelchair.

You asked the Plan to pre-approve an electronic connection and push handles. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because an electronic connection is not medically necessary and push handles are not a Medicare benefit.

We decided the Plan does not have to pre-approve an electronic connection:

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 an electronic connection. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that you do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength and function in the right upper extremity with the ability to feed yourself indicates that you can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection not been met.

We decided the Plan does not have to pre-approve push handles: 

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

Push handles do not serve a purpose that is primarily medical in nature. Therefore, Medicare rules for coverage of push handles have not been met.

Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2310) and push handles (K0108) for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the shoulders and left knee for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show that these tests will help.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found x-rays of both areas have been performed. The left knee x-ray on November 2, 2020, showed no effusion but degenerative changes especially medial compartment. There is no physical exam showing instability or effusion in the medical records. The right shoulder x-ray on January 31, 2020, showed degenerative changes and findings consistent with long-standing rotator cuff tear. There is no detailed physical exam in the records. The chart indicates that the enrollee continues to do exercises, but there is no record of a monitored six-week physical therapy program to show progress. Absent any red flags mandating immediate imaging, the medical necessity of the requested MRIs have not been established.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the shoulders and left knee for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with accessories.
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you have diabetes and pushing a
wheelchair with your feet causes foot problems. The Plan denied your request. The Plan says the denial of
authorization for this device is correct, because you do not have a neurological and/or muscular disorder
causing your mobility deficit.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3
power wheelchair with accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 9,
2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan
denied your request. The Plan says code 97530-GO, CO, KX cannot be paid. This code represents direct (oneon-
one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes,
however the records indicate that the service is performed by an occupational therapist assistant in a home
health or hospice setting. A more appropriate code (G0158) is used or should be used for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due
to an error with the code used. The Plan states a corrected claim would be reviewed. Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee on December 9, 2020.