Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on October 29, 2020.

You asked the Plan to waive the copayment for a specialist office visit. You say that you saw a nurse. You say that you made sure this was not a specialist. 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 $10 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a $10 copayment for a specialist office visit. The nurse that you saw is considered a specialist; therefore, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 specialist office visit provided by a participating provider on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve the CPAP device. You say that you require the device. The Plan denied your request. The Plan says you did not meet the adherence to therapy aspect of criteria coverage.

The Plan must follow Medicare rules. Medicare rules say that there must be objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. There is no documentation of adherence to the therapy that meets Medicare coverage criteria standards.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer from one skilled nursing facility (SNF) to another SNF.

You asked the Plan to pre-approve transfer from one SNF to another SNF. You say that the requested transfer from one SNF to another SNF is medically necessary. The Plan denied your request. The Plan says the requested transfer from one SNF to another SNF is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.

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 transfer from one SNF to another SNF. Our reviewer says that the requested transfer from one SNF to another SNF is not medically necessary. Our physician reviewer found the enrollee is with a past medical history of dementia who resides in a long-term care facility. A transfer from one nursing facility to another nursing facility has been requested by family. At issue in this case is whether the requested transfer is necessary and reasonable to meet the enrollee's needs and to improve and maintain the enrollee's overall health status.

Based on the medical records provided there is no documentation that the requested transfer is medically necessary; there is no documentation that the facility where the enrollee is presently residing is unable to meet the enrollee's health 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 transfer from one SNF to another SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve transfer from one skilled nursing facility (SNF) to another SNF.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) provided November 30, 2020.

You asked the Plan to pay for the CT scan. You say that the enrollee was not enrolled in hospice for this date of service. 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 member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on November 16, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) provided November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a respiratory assist device (E0471) for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not been compliant.

The Plan must follow Medicare rules. Medicare rules say that failure of the beneficiary to be consistently using the E0471 for an average of 4 hours per 24 hour period by the time of the re-evaluation (on or after 61 days after initiation of therapy) would represent non-compliant utilization for the intended purposes. 

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found BiPAP is considered not medically necessary because the enrollee is unable to use the device sufficiently for it to be effective. Many efforts have been made to address interface intolerance, without success. The enrollee has been unable to use the device enough to meet the minimum Medicare requirements: at least 4 hrs/day for at least 70% of days. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a respiratory assist device (E0471) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitors (CGMs) defined by codes K0554, K0553.

You asked the Plan to pre-approve the CGMs. You say that the CGM is necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGMs have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitors (CGMs) defined by codes K0554, K0553.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple power options for a group 3 power wheelchair (E2300, E2377, E2311, E2313).

You asked the Plan to pre-approve the power options for a group 3 power wheelchair. You say that the enrollee requires these options. The Plan denied your request. The Plan says the power wheelchair options are not necessary.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.

We asked our 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 power options for a group 3 power wheelchair. Our reviewer says that the power wheelchair options are not necessary. Our reviewer found a Seat Elevator (E2300) does not serve a primary medical purpose and is statutorily non-covered. A Electronic connection (E2311), Expandable Controller (E2377) and Expandable Controller Harness (E2313) cannot be covered as it is not necessary to control the three requested power options through the joystick (drive interface). 

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 power options for a group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple power options for a group 3 power wheelchair (E2300, E2377, E2311, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99231) and the electroencephalogram (EEG), continuous recording (95720) rendered by the out of network (OON) provider on January 6, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 subsequent hospital care, per day (99231) and the electroencephalogram (EEG), continuous recording (95720) rendered by the out of network (OON) provider on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the Plan's benefit representative told you the provider was in-network. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from April 14, 2019 to April 17, 2019.

You asked the Plan to pay for acute inpatient hospital care. You say that this is not medically necessary. The Plan denied your request. The Plan says that the level of care was appropriate in duration, extent, and was not experimental and investigative.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the enrollee was admitted with hip pain following failure to thrive at home after surgery. The enrollee was noted to have a urinary tact infection, dehydration as evidenced by laboratory studies, and sacral decubiti. The ER admission note and history and physical by attending both demonstrated the reasonable expectation of more than a two night stay. The elements of the coverage rule are satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from April 14, 2019 to April 17, 2019.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 22, 2021 by a non-participating 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 a non-participating 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. 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 office visit provided on January 22, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81161, 81407, 81408, 81439) provided October 30, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. 

We looked at the file and Medicare rules. The services at issue are cardiovascular risk assessment panels. This type of testing is not covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81161, 81407, 81408, 81439) provided to the enrollee October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81406, 81407, 81408) provided December 21, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

We looked at the file and Medicare rules. The test performed were cardiovascular risk assessments. These tests are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81406, 81407, 81408) provided December 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance services (A0429) provided on January 11, 2021

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 based on the documentation provided, other means of transportation were not contraindicated and could have been used without endangering the enrollee's health.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.

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 services. Our reviewer says that the services at issue in this case were not medically reasonable or ne necessary. Our physician reviewer found there were no presenting symptoms or vital signs that would indicate a need for ambulance services to the emergency room. Vital signs were normal, and he was able to ambulate. Abdominal exam findings did not demonstrate rebound or guarding.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency ambulance services (A0429) provided on January 11, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve spinal pain injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no record of functional deficit, prior non-invasive care, or lumbar spine imaging.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 injections. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the progress note documents imaging of the spine. The prior injection was on 9/30/20 and produced 50% pain relief.

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 injections have been met. Therefore, we decided that the Plan has to pre-approve spinal pain injections for the enrollee.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services from November 17, 2020, to November 18, 2020.

You asked the Plan to waive the copayment for the emergency department services. You say that you shouldn't have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Emergency Care. 

You have been asked to pay a $100 copayment for the emergency department services. The emergency department services fall within the Emergency 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 the emergency department services from November 17, 2020, to November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99212) radiologic examination, spine, lumbosacral (72100) provided August 31, 2020 to December 8, 2020.

You asked the Plan to pay for the office visit and x-ray. You say that before you signed up for the chiropractic treatment you called the plan and understood the doctor was not in network so the plan would cover 60% instead of 80%. So far the plan has only paid $209.08 The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% coinsurance for out of network Medicare covered chiropractic services. Claims for 98941 were reprocessed to show correct benefit of 40% coinsurance for out of network chiropractic services.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99212) radiologic examination, spine, lumbosacral (72100) provided August 31, 2020 to December 8, 2020.