Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pay for IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 pay for 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical therapy and occupational therapy services, based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Finally, you will not be able to fully participate in and benefit from the intensive rehabilitation therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care.

You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested services are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric care. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that, based upon review the records provided, the enrollee does not meet the criteria for acute inpatient mental health treatment and could be treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety while awaiting placement.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under codes 17311 and 17312.

You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says the codes submitted are not supported because the documentation does not indicate the provider acted in two (2) separate and distinct capacities. The Plan notes there is a more appropriate Current Procedural Terminology (CPT) code (11643) for the standard excision of a malignant lesion that should be used for the service billed. The Plan notes a corrected claim would be reviewed if submitted.

The Plan must follow Medicare rules. The rules state that providers may bill services with a modifier if the service billed with the modifier indicates a distinct procedural service. It also appears based on the coding guidelines that there is a more appropriate code that should be used for the services provided. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee and billed under codes 17311 and 17312.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81408, 81401, 81406, 81400, 81225, 81226,
81227, 81230, 81231, 81232, 81240, 81241, 81256, 81283, 81291, 81328, 81335, 81350, 81355, and 81479)
provided on September 30, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan
denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. If no CPT code accurately describes the
procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure)
with one unit of service or may report multiple individual CPT codes describing the component test results
when medically reasonable and necessary.
We find that CPT codes 81408, 81401, 81406, 81400, 81225, 81226, 81227, 81230, 81231, 81232, 81240,
81241, 81256, 81283, 81291, 81328, 81335, 81350, 81355, and 81479 are not supported in the medical record.
Specifically, this testing should be reported with either one unit of 81479 or multiple CPT codes describing the
component test results. Billing multiple units of 81479 as well as component codes is not appropriate in this
case. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81408, 81401, 81406, 81400,
81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81256, 81283, 81291, 81328, 81335, 81350, 81355,
and 81479) provided on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lovenox solution for home use.

You asked the Plan to pre-approve self-administered drug. You say that the enrollee is at immense risk of recurrence without this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lovenox solution for home use.

Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the two crowns.

You asked the Plan to reimburse you for the dental service. You say that you paid $1,277 for the porcelain
crown. You say that you have a $300 dental allowance per year. You also say that you thought it covered any
dental procedure, not just preventive services. The Plan denied your request. The Plan says there is a $300
allowance per year for preventive dental services. The Plan says that crowns are not a preventive service. The
Plan also says that crowns are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for
the two crowns.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit provided by an out of network (OON) provider.

You asked the Plan to pay for an outpatient clinic visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or a participating provider.

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 an outpatient clinic visit 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 21, 2020, by an out-of-network provider.

You asked the Plan to pay for the services provided. You say that you did not realize that your follow-up appointment would not be covered. The Plan denied your request. The Plan says the services were not urgent or emergent.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 21, 2020, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.

You asked the Plan to pre-approve aquatic therapy. You say that aquatic therapy is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.

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 aquatic therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record documentation does not support that you have a new injury or change in quality of pain suggesting a different pathology. The medical records show you have had adequate skilled physical therapy that would be reasonably needed to establish a home exercise program. The goal of physical therapy is eventual independence with a home exercise program to maintain strength and function. In this case, there is not an established appropriate duration and frequency of treatment that would be considered appropriate for your medical condition that would allow approval of aquatic therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion device (22869, 22870).
You asked the Plan to pre-approve the surgery to place a Vertiflex Superion device. You say that the treatment is safe and effective and should be covered. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 surgery to place a Vertiflex Superior device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery to place a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitors (CGM) external receiver and sensors (CPT A9278 and A9276).

You asked the Plan to pre-approve a CGM external receiver and sensors. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM external receiver and sensors. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no evidence that the enrollee uses the results of blood glucose testing to self-adjust insulin dosages multiple times per day. 

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 CGM external receiver and sensors have not been met. Specifically, the enrollee does not meet the criteria for a CGM, and therefore, the CGM external receiver and sensors are not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitors (CGM) external receiver and sensors (CPT A9278 and A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DyAnsys P-stim electro-acupuncture device.

You asked the Plan to pre-approve a DyAnsys electro-acupuncture device. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered. 

We looked at the file and Medicare rules. The requested device is non-covered. Based on this information, we decided that Medicare rules for coverage of a DyAnsys electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve a DyAnsys P-stim electro-acupuncture device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rear basket (K0108) for a power scooter.

You asked the Plan to pre-approve the basket. You say that this is medically necessary. The Plan denied your request. The Plan says the requested rear basket is not primarily and customarily used to serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item 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 a rear basket (K0108) for a power scooter.
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 your mother is on a fixed income and has a bladder condition. The Plan denied your request. The Plan says this item is not a covered benefit.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with an optometrist (99213) provided October 27, 2020.
You asked the Plan to waive the copayment for the office visit with an optometrist. You say that your office visit should have been billed as your annual routine eye exam with no copayment. The Plan denied your request. The Plan says the office visit was confirmed by the provider to be for refraction only services and thus the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $40 copayment for the office visit with an optometrist for refraction only services that did not include a routine eye exam. This service falls within the Vision 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 office visit with an optometrist (99213) provided October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI).

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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that services rendered to a registered inpatient must be billed with POS code 21.

We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 22 for outpatient hospital; however, the enrollee was under inpatient status for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis.

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 there is no valid physician order.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.

We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee needs this item. The Plan denied your request. The Plan says records have not been submitted that show the criteria for coverage are 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. No medical records have been submitted to show that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires 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 a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you know this doctor is very highly recommended. The Plan denied your request. The Plan says there are in-network providers available for 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 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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bridge.

You asked the Plan to pre-approve a dental bridge. You say that because of a medical condition you need a bridge so you can eat and drink properly. The Plan denied your request. The Plan says dental bridges are not a covered item under your dental 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. Therefore, we decided that the Plan does not have to pre-approve a dental bridge.