Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on February 18, 2021.

You asked the Plan to pay for an eye refraction. You say that under your Plan, after cataract surgery, you are entitled to corrective eyeglasses and the associated exam to determine the lens prescription for the eyeglasses. The Plan denied your request. The Plan says all refractive procedures are excluded from Medicare coverage.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan pays for one pair of eyeglasses with standard frames after cataract surgery. The eye refraction is not a covered benefit. 

We looked at the file and the Plan's rules. The eye refraction is not a covered benefit under this Medicare Plan. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 2, 2020.

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 services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 2, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 6 additional speech therapy visits.

You asked the Plan to pre-approve 6 additional speech therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

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 pre-approve 6 additional speech therapy visits. Our reviewer says that the services are medically necessary. Our physician reviewer found based on the medical records provided there is documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. The latest report from the speech therapist dated August 17, 2021 indicates you are benefiting from therapy and making progress but is still limited with regard to memory and attention and that you will continue to benefit from therapy to achieve the planned goals. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional speech therapy visits have been met. Therefore, we decided that the Plan has to pre-approve 6 additional speech therapy visits.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 27, 2021.

You asked the Plan to pay for foot orthotics. You say that the shoes requested have been approved. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the smoking and tobacco use cessation counseling visit provided on February 1, 2021.

You asked the Plan to pay for Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (99406). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the diagnosis code is incorrect.

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. The medical records show the enrollee has signs and symptoms of tobacco-related disease. Based on this information, we decided that Medicare rules for coverage of smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (99406) have not been met. Therefore, we decided that the Plan does not have to pay for the smoking and tobacco use cessation counseling visit provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2020.

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 claims were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan.
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option (K0856) with power tilt (E1002) and accessories.

You asked the Plan to pre-approve a Group 3 power wheelchair with single power option and power tilt. You say that the requested power wheelchair is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power option is covered if the enrollee meets coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair. 

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 a Group 3 power wheelchair with single power option and power tilt. Our reviewer says that the requested item is not medically necessary in this case. Our physician reviewer found that, based on the medical records provided, there is no documentation that you meet Medicare criteria for a power seating system with power leg rests; there is no documentation of spasticity, high risk for skin breakdown or the need for intermittent catheterization. Consequently, there is no documentation that you meet Medicare criteria for a power wheelchair coded K0856 as records do not document the need for power tilt or recline. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 3 power wheelchair with single power option and power tilt have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option (K0856) with power tilt (E1002) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient consultation and a follow-up office visit to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 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 services. Therefore, we decided that the Plan does not have to pre-approve a new patient consultation and a follow-up office visit to be rendered by the out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 13, 2021, through February 24, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services are not medically necessary and required prior authorization.

The Plan contract says that SNF services require prior authorization and a referral.

We looked at the file and the Plan's rules. The file shows that prior authorization was not obtained for the SNF services. 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 SNF services provided from
February 13, 2021, through February 24, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lower extremity for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical notes do not indicate than an MRI was requested or needed.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found it is well-established in the medical documentation that this diabetic patient is suffering with a long-standing ulceration to the left hallux. The enrollee has failed conservative treatments debridement, oral antibiotics, dressing changes, and offloading the area. On 7/19/21 the enrollee's physician recommended and ordered an MRI of the left foot to check the extent of infection which will determine the surgical options and extent of bone debridement. The guidelines advise that an MRI is covered when medically necessary and reasonable for the diagnosis or treatment of a specific patient involved. In this particular case the MRI will be utilized for surgical planning.

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lower extremity for the enrollee.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 20, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that this was your first visit this year to the dentist so the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 years.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on February 12, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor.

You asked the Plan to preapprove the continuous glucose monitor. You say that the CGM is necessary. The Plan denied your request. The Plan says you do not meet coverage criteria.

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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate care.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision of a wrist ganglion (25111) to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal.

We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve the excision of a wrist ganglion (25111) to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an OON provider.

You asked the Plan to pre-approve the OON power wheelchair. You say that the power wheelchair is medically necessary and supported by the records provided. The Plan denied your request. The Plan says medically necessary items and services are available within the enrollee's network. The Plan says that there are no extenuating circumstances making it medically necessary to obtain the power wheelchair out of network.

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-approve a power wheelchair to be provided by an OON provider.
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 in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional home health visits for skilled nursing services (G0299).

You asked the Plan to pre-approve home health skilled nursing visits. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health skilled nursing visits. Our reviewer says that the requested services are not medically necessary in this case. Our physician reviewer found that the enrollee does not have documented skilled nursing needs (such as complex wound care, intravenous drugs, new ostomy, frequent medication changes). The enrollee's needs appear to be custodial. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional home health visits for skilled nursing services (G0299).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 23, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. 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 the services provided by an out-of-network provider on November 23, 2020.