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

We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G Orthosis (L8702).
You asked the Plan to pre-approve the MyoPro 2 Motion G Orthosis. You say that this requested equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is considered experimental/investigational.
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 MyoPro 2 Motion G Orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 MyoPro 2 Motion G Orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro 2 Motion G Orthosis (L8702).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergent transportation trips.
You asked the Plan to provide coverage for additional non-emergent transportation trips. You say that you cannot afford transportation to get to your therapy appointments. The Plan denied your request. The Plan says you have exhausted your benefit for this year.
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 40 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that you have surpassed the benefit limit as you have already used 55 one-way trips this year. 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 provide coverage for additional non-emergent transportation trips
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.

You asked the Plan to pre-approve the surgical extraction. You say that your dentist is unable to provide the extraction because you need to be put under. The Plan denied your request. The Plan says dental services performed by an oral surgeon 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 covered when they are provided by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 89-year-old male with diabetes, neuropathy, coronary artery disease, and chronic kidney disease. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 27, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met as a valid physician order was not submitted.

The Plan must follow Medicare rules. Medicare rules say that services must be ordered by the appropriate physician or allowed non-physician treating the enrollee. In this case the documentation provided does not clearly support this testing was ordered by the physician or practitioner currently treating the enrollee. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone 5 mg tablet.
You asked the Plan to pre-approve Prednisone. You say that this requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Prednisone 5 mg tablet.
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you feel you meet criteria for the requested services. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria.
We reviewed the file and the Medicare rules. We find that the documentation does not support that you have a
30 pack a year smoking history. The documentation shows that you have had a 15 pack a year smoking history.
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT)
scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the radiofrequency ablation services. You say that the clinical information provided supports the need for the requested services. The Plan denied your request. The Plan says there is no clinical information documenting medical necessity that meets the criteria for coverage.
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 radiofrequency ablation services. Our reviewer says that the requested radiofrequency ablation services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral sacral branches is considered experimental/ investigational because of the wide variation in efficacy reported.
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 radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have any daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73060 provided on January 14, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 77030 is radiologic examination; humerus, minimum of 2 views. We find that CPT code 77030 is not supported in the medical record. Specifically, there are two claims on file for this code. One billed with a RT (right) modifier and one billed with a LT (left) modifier. The RT claim was paid at 100% of the fee schedule; therefore, separate payment is not allowed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73060 provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on August 14, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 to the enrollee on August 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet requirements for an IRF admission and could receive care in another setting such as a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown represented by code D2751 and core buildup services represented by code D2950.
You asked the Plan to pre-approve codes D2751 and D2950. You say that you cannot afford to pay out of pocket for a crown that should be covered by your plan. You say that you are in pain and cannot chew. The Plan denied your request. The Plan says the services in dispute are 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 a
dental crown represented by code D2751 and core buildup services represented by code D2950.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for to make additional payment for the non-emergency ambulance trips plus the additional supplies described by code A0999 provided on January 8, 2020.

You asked the Plan to pay for the non-emergency ambulance trips and additional supplies. You say that you needed to be transported to your appointments by ambulance because you were bedridden at this time. The Plan denied your request. The Plan says the requested items are not a covered benefit under your plan.

The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The rules also say that payment under the fee schedule for ambulance services includes a base rate payment plus a separate payment for mileage. This payment covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance trips and additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for to make additional payment for the non-emergency ambulance trips plus the additional supplies described by code A0999 provided on January 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (HBO).
You asked the Plan to pre-approve Hyperbaric Oxygen Therapy (HBO). You say that you have no hearing in your left ear and your balance is off and you have an issue when watching TV and speaking with people. The Plan denied your request. The Plan says your medical records do not reflect you meet Medicare criteria as the medical records do not document that you have been diagnosed with any of the conditions for which Medicare provides coverage for HBO Therapy.
The Plan must follow Medicare rules. Medicare rules say that Hyperbaric Oxygen Therapy (HBO) will be limited to that which is administered in a chamber (including the one-man unit) and is limited to specific conditions.
We looked at the file and Medicare rules. The file shows that you are requesting coverage for Hyperbaric Oxygen Therapy (HBO) for hearing loss. Based on this information, we decided that Medicare rules for coverage of Hyperbaric Oxygen Therapy (HBO) have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (HBO).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on February 4, 2021.
You asked the Plan to pay for a telehealth visit. You say that Medicaid providers have been instructed to use the home place of service for telehealth. The Plan denied your request. The Plan says Medicare requires telehealth services to be billed with the telehealth place of service.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on February 4, 202
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for durable medical equipment provided by a participating provider on November 30, 2020.
You asked the Plan to waive the deductible for durable medical equipment. You say that you do not agree with this amount. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,300 deductible for durable medical equipment. The item or service you asked the Plan to waive the deductible for falls within the benefit category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,300 deductible for durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time durable medical equipment was received on November 30, 2020. The total amount you are being asked to pay is $136.77. Therefore, we decided that the Plan does not have to waive the deductible for durable medical equipment provided by a participating provider on November 30, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the deductible for the inpatient skilled nursing (SNF) care provided from January 25, 2021, through February 1, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the deductible was applied correctly to the services provided.

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, an Evidence of Coverage (EOC) booklet that pertains to the year 2020 was incorrectly provided in this case. Therefore, we decided that the Plan has to waive the deductible for the inpatient skilled nursing (SNF) care provided from January 25, 2021, through February 1, 2021.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for Medicare Part B drugs
provided on January 12, 2021.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The
Plan denied your request. The Plan says this coinsurance was applied per the Plan contract agreement.
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 20%
coinsurance for Medicare Part B drugs and administration. 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 20% coinsurance charged
for Medicare Part B drugs provided on January 12, 2021.