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

We decided that the Plan does not have to pre-approve an electric hospital bed (E0265).
You asked the Plan to pre-approve an electric hospital bed. You say that the requested item is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. 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 electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided in this case there is no documentation to support that a hospital bed is medically necessary for this enrollee. None of the provided records report that the enrollee's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or that the enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed. 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 electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric hospital bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation of the veins.
You asked the Plan to pre-approve endovenous ablation. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not had a 3-month trial of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation may be covered as medically necessary after a 3-month trial of conservative therapy and duplex studies of the involved lower extremities. 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 endovenous ablation. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested endovenous ablation. Our physician reviewer found the enrollee has not had a documented 3-month trial of conservative therapy including graduation compression stockings, weight reduction, or an exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation of the veins.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 23, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 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 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 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 a domiciliary or rest home visit provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that your physician provided these services in good faith. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's non-participating nursing facility referred 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 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 skilled nursing services provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care supplies, roll gauze (A6446), tape (A4450), cohesive bandage (A6454) and Xeroform (A6223) provided August 22, 2019.
You asked the Plan to pay for the wound care supplies. You say that the claim should have been paid and you request reconsideration of the denial. The Plan denied your request. The Plan says DME must be supplied to the beneficiary as part of the SNF services and may not be billed separately to the insurance. Payment to the DME provider is the responsibility of the SNF.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wound care supplies was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for wound care supplies, roll gauze (A6446), tape (A4450), cohesive bandage (A6454) and Xeroform (A6223) provided August 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy services (97110) provided from February 7, 2020 to February 28, 2020.You asked the Plan to pay forphysical therapy services. You say that these services were necessary to maintain the enrollee's quality of life.The Plan denied your request. The Plan says these services were not necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy was generally not accepted as specific and effective therapy for the patient's condition. The patient's knee condition is chronic and she has had prior therapy for this condition per documentation. She did not require the skills of a professional therapist. The 3/3/20 therapy note states that the patient was given cues to improve weight shifting and step length with minimal carryover most notably due to degenerative changes right knee. She does not need the unique skills of a professional therapist to safely and effectively provide treatment. Services did not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist was not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay forphysical therapy services (97110) provided from February 7, 2020 to February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve baby monitor, commode liners, and Heppa filter.
You asked the Plan to pre-approve baby Monitor, commode liners, and Heppa filter. You say that all of these items are medically necessary. It has nothing to do with convenience, but is a medical safety necessity. The Plan denied your request. The Plan says these are convenience items and are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve baby monitor, commode liners, and Heppa filter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 16, 2020, March 20, 2020 and March 25, 2020.You asked the Plan to pay for the chiropractic services. You say that this chiropractor is close to your home and it is difficult for you to travel. You say that his treatments work better for you than other chiropractor's treatments. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 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 chiropractic services provided on March 16, 2020, March 20, 2020 and March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the osseous surgery (D4260) for all 4 quadrants provided from February 5, 2019 to August 8, 2019 by an out of network provider.You asked the Plan to reimburse the full amount for the dental services. You say that you have gum disease. You say that on January 8, 2019 you made a down payment for the dental services that you would receive on the dates of service.The Plan denied your request. The Plan says the $1,000 annual maximum has been exhausted.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 annual maximum of $1,000 has been exhausted. Therefore, we decided that the Plan does not have to reimburse the full amount for the osseous surgery (D4260) for all 4 quadrants provided from February 5, 2019 to August 8, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy (97140) provided May 13, 2019 to November 16, 2019.
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 these services are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. Medicare rules say that the only covered chiropractic service is manual manipulation of the spine to correct a subluxation. Additionally, Medicare pays for outpatient rehabilitation therapy services only when they are provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that these services were provided by either chiropractors or licensed massage therapists. The record does not indicate that the services were provided by a qualified professional specifically trained to furnish therapy services. Therefore, we decided that the Plan does not have to pay for the manual therapy (97140) provided May 13, 2019 to November 16, 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-approve the LTACH services. 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 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 you were admitted to an acute care hospital (ACH) for treatment of pneumonia. You were not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound (76830) provided on January 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe ultrasound. You say that the services were medically necessary.The Plan denied your request. The Plan says there were network providers available. The services were not emergent or preauthorized.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 forthe ultrasound (76830) provided on January 29, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography services (77063, 77067) provided on
February 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the mammography services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were
network providers available.
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 the mammography services (77063, 77067)
provided on February 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a carrying case for a wheelchair. You asked the Plan to pre-approve the case. You say that this is medically necessary.The Plan denied your request. The Plan says this is not needed for within the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a carrying case for a wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the wrist hand orthosis provided on December 9, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), and the wrist hand orthosis (L3916). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not contain evidence of a relationship with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the wrist hand orthosis provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction with anesthesia.
You asked the Plan to pre-approve the dental services. You say that the enrollee's tooth is not being extracted due to dental decay. You also say that the enrollee needs their tooth extracted due to significant vertical bone loss. The Plan denied your request. The Plan says the services you are requesting are dental in nature. The Plan says that extractions due to significant vertical bone loss is not covered under your medical plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the extraction with anesthesia.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the physical therapy services provided on February 27, 2020.
You asked the Plan to pay for the physical therapy services. You say that range of motion improvements are
achieved slowly as it is difficult to mobilize and maintain length of the affected tissues. The Plan denied your
request. The Plan says that the enrollee appears to be at her highest level of function.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee received physical therapy services by a contract provider. The file does not show that the plan
provided notice prior to the services being rendered that the physical therapy services would not be covered.
Under Medicare rules, this means the physical therapy services is considered approved by the plan. Therefore,
we decided that the Plan has to pay for the physical therapy services provided on February 27, 2020.
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: 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 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. Your functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment only in a SNF as you are progressing with your current therapy and able to transition to outpatient. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter you do not require the necessary services on 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 skilled nursing facility (SNF) care.