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

We decided that the Plan does not have to pay for sensors for use with an interstitial continuous glucose
monitor.
You asked the Plan to pay for sensors for use with an interstitial continuous glucose monitor (A9276). You say
that the enrollee needs sensors for a Medtronic Guardian CGMS. The Plan denied your request. The Plan says
this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor.
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 A9276 is Sensor; invasive (e.g., subcutaneous),
disposable, for use with interstitial continuous glucose monitoring system.
We find that CPT code A9276 is not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of sensors for use with an interstitial continuous glucose monitor have not been
met. Therefore, we decided that the Plan does not have to pay for sensors for use with an interstitial continuous
glucose monitor.
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 enrollee's health will decline without rehab. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 services are not medically necessary. Our physician reviewer found the enrollee underwent surgical repair for a femur fracture on March 8, 2020. He needs minimal assistance for bed mobility, transfers, and ambulation. He has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from additional physical and occupational therapy but does not require an intensive therapy program 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (K0554) and sensors (K0553).
You asked the Plan to pre-approve continuous glucose monitor and sensors. You say that it will be beneficial for the enrollee to switch from Freestyle Libre to Dexcom to keep him save as the enrollee has hypoglycemia unawareness. The Plan denied your request. The Plan says this request is not medically necessary as the enrollee received a CGM less than 1 year ago. Medicare does not allow replacement of any durable medical equipment that is less than 5 years old.
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. Records show that the enrollee received a Freestyle Libre in 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor and sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (K0554) and sensors (K0553).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveair ambulance transport (A0430, A0435).You asked the Plan to pre-approveair ambulance transport. You say that you live in North Carolina and you want to be transported back home.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance transport. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the documentation does support that you suffer from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation does not support that your condition was such that the time needed to transport you by ground, or the instability of transportation by ground, posed a threat to your survival or seriously endangered your health. The documentation does not support that the transferring hospital does not have adequate facilities to provide the medical services needed by you.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transport have not been met.Therefore, we decided that the Plan does not have to pre-approveair ambulance transport (A0430, A0435).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve physician services. You say that the cost for you to go out-of-state would be a financial burden. You say that you have already paid out of pocket for this doctor. You say that you want to have this fixed permanently.The Plan denied your request. The Plan says there are 18 orthopedic specialists within 50 miles of the member.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-approvephysician services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray of the hip (73502) provided October 4, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $45 copayment for Routine Radiology. You have been asked to pay a $45 copayment for the x-ray. The x-ray falls within the Routine Radiology 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 X-ray of the hip (73502) provided October 4, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc (J7320).
You asked the Plan to pre-approve Genvisc. You say that the enrollee has failed Orthovisc and Monovisc is inappropriate. The Plan denied your request. The Plan says the enrollee has not tried Monovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc. Our reviewer says that the criteria for coverage of Genvisc have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. There is no documentation of trial and failure of Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc (J7320).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on September 19, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved
for payment. 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 has network providers
available who can provide 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 lab services provided on September 19, 2019 by
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required,
(D2950).
You asked the Plan to pre-approve the core buildup. You say that the enrollee was advised to replace the old
crown for proper protection and function. The Plan denied your request. The Plan says Medicare does not cover
this service and therefore this service is not covered by 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. Therefore, we decided that the Plan does not have to pre-approve a
core buildup, including any pins when required, (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory servicesprovided on November 6, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that thePlan 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 servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a home blood pressure monitor.You asked the Plan to provide a home blood pressure monitor (A4670). You say that your doctor is requiring you to monitor your blood pressure daily.The Plan denied your request. The Plan says the record shows you are not on home dialysis.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plan does not have to provide a home blood pressure monitor
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from October 12, 2019 to November 10, 2019.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the services provided are considered custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our physician reviewer found that the enrollee's level of function at the time of discontinuation of therapies was moderate assist with transfers, moderate/maximal assist to don prosthetic leg, non-compliant with weight bearing restrictions, wheelchair mobility of 20 feet independently, moderate/maximal assist with bed mobility, set-up with upper body activities of daily living (ADLs), moderate assist with toilet transfers, and maximal assist with lower body ADLs. There were no noted daily skilled complex nursing needs. While he may have benefited from continuing physical and occupational therapy, the records do not support the need for daily therapy. His needs were custodial in nature.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from October 12, 2019 to November 10, 2019.
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-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 based on the provided medical records the enrollee is receiving the necessary services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee's caregiver cannot crank the bed for height adjustment. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on July 12, 2018 and the epidural injection provided on October 15, 2018.You asked the Plan to waive the copayment for the lumbar injection and epiduralinjection. You say that the injections were in the doctor's office. You say that you are owed $200 for each procedure.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrolleesin clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment per date of service for outpatient surgery at an outpatient hospital facility.The enrollee has been asked to pay a $400 copayment for the lumbar injection and a $400 copayment for the epidural injection. The total amount the enrollee owes is $800 ($400/injection x 2 injections = $800). The lumbar injection and epidural injectionfallwithin the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The lumbar injections are considered a surgical service that werebilled by the hospital. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the lumbar injection provided on July 12, 2018 and the epidural injection provided on October 15, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging provided on August 16, 2019.
You asked the Plan to waive the coinsurance for the myocardial perfusion imaging. You say that you were informed the test cost $50. You say that you shouldn't be responsible. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for each Medicare-covered diagnostic imaging service. You have been asked to pay $234.84, which is 20% of the allowed amount for the myocardial perfusion imaging. The allowed amount is $1,174.22 (20% x $1,174.22 = $234.84). The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the follow up visit (99213) provided on September 6, 2019.
You asked the Plan to pay for the follow up visit (99213). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 Plan's Evidence of Coverage shows the enrollee has Point of Service benefits. This benefit, per the Plan contract, allows the enrollee to go to out-of-network providers, including in the United States and its territories. Therefore, we decided that the Plan has to pay for the follow up visit (99213) provided on September 6, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin substitute graft and Artacent wound patch.
You asked the Plan to pre-approve skin substitute graft and Artacent wound patch. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was evaluated for a new wound on March 2, 2020. The Plan states the requested application of skin substitute graft is not medically necessary at this time as there is only documentation of 10 days of a new non-healing wound.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare says Chronic Wounds are defined as wounds that do not respond to standard wound treatment for at least a 30-day period during organized comprehensive conservative therapy. The file does not show that a 30-day period of no response to standard wound treatment has passed. Based on this information, we decided that Medicare rules for coverage of skin substitute graft and Artacent wound patch have not been met at this time. Therefore, we decided that the Plan does not have to pre-approve skin substitute graft and Artacent wound patch at this time.