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

We decided that the Plan does not have to pre-approve a Freestyle Libre CGM.

You asked the Plan to pre-approve a CGM. You say that the requested item is beneficial to you and that the usage of Freestyle Libre is a potential major cost savings to the Plan. The Plan denied your request. The Plan says rules for pre-approval have not been met.

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 case record indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre CGM.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Partial Hospitalization Program admission.

You asked the Plan to pre-approve the Partial Hospitalization Program admission. You say that you would like
reconsideration because the member needs a higher level of care than outpatient therapy. The Plan denied your
request. The Plan says the member can be safely and effectively treated in a lower level of care.

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 Partial Hospitalization Program
admission. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the member has chronic conditions which could be treated
at a lower level of care including in intensive outpatient 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 the Partial Hospitalization Program admission have not been met. Therefore, we
decided that the Plan does not have to pre-approve Partial Hospitalization Program admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is requested for use outside of the home in the backyard.

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 group 2 standard power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a Group 2 power wheelchair and accessories. The Plan denied your request. The Plan says you have not had a specialty evaluation or a home evaluation.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair or you can safely operate the PMD being requested. There is no home assessment or specialty evaluation documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, the intraoral - periapical first radiographic image, and the removal of plaque services received on October 23, 2020.
You asked the Plan to pay for the periodic oral evaluation, the intraoral - periapical first radiographic image, and the removal of plaque services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received 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. While the plan does cover oral exams and adult prophylaxis once per calendar year, the documentation shows that you previously received this service on January 28, 2020. One calendar year had not passed since you previously received these services. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, the intraoral - periapical first radiographic image, and the removal of plaque services received on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enroll has memory issues and a therapeutic continuous glucose monitor would be a highly effective tool to keep track of blood sugar. The Plan denied your request. The Plan says criteria is not met for a therapeutic continuous glucose monitor.
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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from January 10, 2020, through March 2, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there is no authorization on file for these services.

The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to participate in the Medicare program. 

We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from January 10, 2020, through March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) provided on October 20, 2020.
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.
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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam rendered on June 27, 2019.
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 claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for these services was not filed until November 13, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the eye exam rendered on June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99231) provided July 9, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for this service was included in payment for the primary service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99231 is not supported in the medical record. Specifically, these services were post-operative care and payment for them was bundled in payment for the anesthesia care package (CPT code 00790). Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99231) provided July 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuation of stay at a skilled nursing facility (SNF) provided from August 22, 0220, to September 20, 2020.

You asked the Plan to pay for SNF services. You say that the services that were rendered are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee has no skilled therapy or skilled nursing service needs. The Plan also says that the enrollee does not meet the Medicare coverage guidelines outlined in the Medicare Benefit Policy Manual for admission to SNF.

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 SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care.

Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the continuation of stay at a skilled nursing facility (SNF) provided from August 22, 0220, to September 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from July
3, 2020, to July 25, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the benefit limit
was exceeded.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone sixty days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from March 25, 2020, to July
3, 2020. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least sixty days in a row. Therefore, we decided that
the Plan does not have to pay for the skilled nursing facility (SNF) services provided from July 3, 2020, to July
25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that RFA is covered for the indications in the applicable LCD. 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 RFA. Our reviewer says that the requested RFA is not medically reasonable and necessary. Our physician reviewer found that the presence of two other pain generators (extruded discs and spinal stenosis) does not meet the LCD criteria. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure requiring mechanical ventilation and COVID 19 pneumonia. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services provided on October 30, 2020.
You asked the Plan to waive the copayment for ophthalmology services. You say that this was a diabetic eye exam so you should not be charged a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist visits. You have been asked to pay a $50 copayment for ophthalmology services. Ophthalmology services fall within the physician/practitioner services, including doctor's office visits 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 ophthalmology services provided on October 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for strapping provided on October 8, 2020, and October 14, 2020.
You asked the Plan to waive the copayments for strapping. You say that you think that the charges are outrageous. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received strapping at an outpatient hospital facility on October 8, 2020, and October 14, 2020. Strapping is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $295 copayment per each date of service. The total amount you owe is: $590. You have been asked to pay the total copayment amount of $590 for strapping. Strapping falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for strapping provided on October 8, 2020, and October 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for atrial fibrillation with rapid ventricular response. She had a cardiac arrest requiring mechanical ventilation and acute renal failure requiring hemodialysis. The enrollee's medical conditions are now stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the medical group has adequate access to in-network specialists.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 medical services provided on September 9, 2020 by an out of network (OON) provider.