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

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The wheelchair has power options approved but the enrollee's strength and function in the upper extremities supports that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
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 service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary.
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 the patient appears to be stable and improving but requires only short-term acute care
to complete treatment which can safely be performed at the current facility. The patient does not require
services at the LTACH that are not already available and/or being administered at the current facility.
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. Specifically, medically necessary
services can be obtained at their current facility.
This means admission into an LTACH is not medically necessary or reasonable. Therefore, we decided that the
Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you feel these items should be covered. The Plan denied your request. The Plan says these are not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on March 15, 2021.
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you should only pay a $45 copayment for the services at issue. 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 $110 copayment for Medicare-covered diagnostic radiology services. You have been asked to pay a $110 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis 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 copayment for a CT scan of the abdomen and pelvis (74177) provided on March 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the psychotherapy (90837) provided from August 19, 2020, through December 16, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not payable as the provider is not eligible to enroll in Medicare.
The Plan must follow Medicare rules. Medicare rules say that licensed professional counselors are not eligible to enroll in the Medicare program. 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 provider in this case is a licensed professional counselor that is not eligible to enroll in Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for the psychotherapy (90837) provided from August 19, 2020, through December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need active, aggressive rehabilitation. You say
that you were fully functional prior to your fall and you are eager to go through acute therapy and need to be
managed by a specialist. The Plan denied your request. The Plan says based on Medicare guidelines and the
information we have about your condition; you don't meet the requirements.

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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for surgical repair of a hip fracture. Your medical conditions are stable. 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. You do 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 you 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health aide services.
You asked the Plan to pre-approve the home health aide services. You say that you have pain in your arms, legs, and back. You state that you need someone to assist at your home because you live alone. The Plan denied your request. The Plan says you do not require skilled services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 pre-approve the home health aide services. Our physician reviewer found the documentation does not support that you require in-home skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The documentation does not support that you are homebound. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary as you do not require any skilled services in the home.
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 home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 30, 2020.
You asked the Plan to pay for a neuromuscular stimulator. You say that this is supported in the records. The Plan denied your request. The Plan says there is not a valid proof of delivery for this item.
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 does not contain a valid proof of delivery for the item provided in this case. While there are delivery tickets included in the submitted documentation, none of them are for delivery dates on or near the billed date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown, for tooth #11 (CPT code D2954) and crown - porcelain/ceramic, for tooth #11 (CPT code D2740).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you received the services within the last sixty (60) months.
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. You received the services within the last sixty (60) months. You may not have the same service to the same tooth in this timeframe. Your handbook states one of D2740- crown-porcelain/ceramic substrate, once per tooth, per sixty (60) months, per patient. One of D2954 - prefabricated post and core in addition to crown, once per tooth per 60 months, per patient. Therefore, we decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown, for tooth #11 (CPT code D2954) and crown - porcelain/ceramic, for tooth #11 (CPT code D2740).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 31, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says both the referring and rendering providers are non-participating with the enrollee's product for the date of service in question. The Plan also says that there is no authorization on file for the services in question.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 31, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 8, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe you qualify for coverage of this service under your dental rider. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on February 25, 2021, and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from August 20 through August 24, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not want to pay the copay because you do not think you should have been in the hospital for four days. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $393 copayment per day for Inpatient Hospital Care. You have been asked to pay a $1,572 copayment ($393 copayment per day for four days) for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay from August 20 through August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on March 9, 2021.

You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician as required per CMS guidelines.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules say that durable medical equipment generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

We find that HCPCS codes L1833 and L2397 cannot be verified in the medical records. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of these orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1833, L2397) provided to the enrollee on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the compression stockings purchased
on November 22, 2020, and December 1, 2020, and the sales tax applied.
You asked the Plan to make additional payment for the compression stockings and sales tax. You say that you
were given two network provider both of which were not able to provide the compression garments you
required. You were told by the Plan to get these from an out-of-network provider and that you could be
reimbursed. The Plan denied your request. The Plan says due to direction by the Plan, it was decided to make
payment toward these items. However, 20% coinsurance was applied, and no payment can be made for the
sales tax.
The Plan must follow Medicare rules. Medicare rules say that Plans must disclose all cost sharing for services
covered. The rules also say that Medicare does not make payment for sales taxes. Your contract with the Plan
says that durable medical equipment and related supplies are covered with 20% coinsurance.
The Plan has made payment toward these items and applied 20% coinsurance. As these items fall into the
durable medical equipment and related supplies benefit category, you have been reimbursed the correct
amount. In addition, the Plan correctly denied payment for the sales tax. Therefore, we decided that the Plan
does not have to make additional payment for the compression stockings purchased on November 22, 2020,
and December 1, 2020, and the sales tax applied.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received April 30, 2021.
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that no other procedures were done on this date of service, and this procedure did not help with your discomfort. The Plan denied your request. The Plan says only one limited oral evaluation procedure is covered per plan year.
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 is limited under this benefit to one procedure per plan year. The Plan last covered the requested service on January 8, 2021. When you received this service on April 30, 2021 the benefit was exhausted and you are responsible for the cost. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.

You asked the Plan to pre-approve the benefits. You say that you have arterial pressure and problems with the eye retina. The Plan denied your request. The Plan says the requested benefits are denied.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The plan rules state that special supplemental benefits are covered under certain specific medical conditions. 

Your medical conditions do not meet the criteria for coverage of this request. Arterial pressure and problems with the eye retina are not listed as covered chronic conditions. Based on this information, we decided that Medicare rules for coverage of the benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311,
E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary, as the
upgraded electronics are necessary to power multiple functions. The Plan denied your request. The Plan says
this is not medically necessary.

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 additional accessories. Our reviewer
says that the requested additional accessories are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of
proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control,
etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to
operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through
the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities
supports that the patient can control any power options through their own individual switches.

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 additional accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the
enrollee.