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

We decided that the Plan does not have to pre-approve the foot orthotics (CPT code L3020).

You asked the Plan to pre-approve foot orthotics. You say that after past bilateral total knee replacements and three left hip replacements, you need the orthotics to keep your feet in proper alignment. You state the one you have been using are worn out do not provide the support that they use to. 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 pre-approve the foot orthotics (CPT code L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity prosthesis replacement components (CPT code(s): L5301, L5620, L5629, L5637, L5645, L5647, L5679, L5685, L5910, L5940, L5980, L5986, L8417), for the enrollee.

You asked the Plan to pre-approve the prosthesis. You say that the lower extremity prosthesis replacement components are medically necessary. The Plan denied your request. The Plan says they do not have information about the manufacturer, or the date the enrollee's previous prosthesis was manufactured. The Plan states they also do not know the reason why a new prosthesis is being manufactured. The Plan states if the enrollee has had recent revision surgery for their lower extremity, this would have an impact on the components of the enrollee's new prosthesis that Medicare will approve. The Plan states without this information, the request is denied.

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 prosthesis. Our physician reviewer found the documents state that that the enrollee has broken the carbon fiber socket and prosthetic foot on the old prosthesis. We do not see recent clinical documentation that address the enrollee's acute medical status changes or detail what the future plans are in terms of weightbearing and wound care. Therefore, the medical necessity for a new replacement right lower extremity prosthesis is not established based on our review of the available documentation. The enrollee was admitted to the acute care hospital on June 14, 2021, for complications related to sepsis from osteomyelitis, right residual limb with erythema/wound and a left foot diabetic ulcer. The enrollee is noted to have a Grade 3 left lateral plant foot ulcer and the right amputation site has exposed subcutaneous tissue and fascia. The clinical information submitted shows that the enrollee is unable to tolerate weight bearing on the residual limb (right below-knee amputation (BKA)) at this time. The enrollee was transferred to a skilled nursing facility on June 14, 2021, for intravenous (IV) antimicrobial treatment. As of July 19, 2021, the enrollee was non-ambulatory due to complex wounds on the left foot and right BKA amputation site. The clinical information does not show that the enrollee will reach or maintain a defined functional level within a reasonable period of time. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity prosthesis replacement components (CPT code(s): L5301, L5620, L5629, L5637, L5645, L5647, L5679, L5685, L5910, L5940, L5980, L5986, L8417), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation investigational in nature and does not support its use since there is no long-term outcome data or continuation rate data at this time.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro orthosis is considered experimental, investigational and unproven when used to help restore function to arms and hands paralyzed or weakened by cerebrovascular accident (CVA) stroke, brachial plexus injury, cerebral palsy or any other neurological or neuromuscular disease or injury.

There is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had on December 9, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this was not a diagnostic test. The Plan denied your request. The Plan says the original claim was processed incorrectly. The Plan has since corrected the claim and you only owe a $70 copayment for this service. The Plan claims that this copayment is correct because the records show this was ordered as a diagnostic, not screening, test.
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 $70 copayment for diagnostic mammography. You have been asked to pay a $70 copayment for the diagnostic mammogram. 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 diagnostic mammogram you had on December 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you believe that SNF care is needed to help with your condition. The Plan denied your request. The Plan says your functional level is not such that daily skilled therapy is required.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has been receiving home health services but has experienced functional decline with acute on chronic pain, weakness, and decreased balance. As of 8/4/2021, she was able to walk 50 feet with contact-guard assistance with a rolling walker. The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 based on review of the limited available records, the enrollee does not meet criteria for an IRF admission. There is no documentation of her nursing needs.

Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While she may benefit from physical therapy, and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee's rehabilitation needs can be easily met at a less intense and alternate level of setting such as in a Skilled Nursing 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 80061, 84443, 85025) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on
November 4, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 laboratory services (36415, 80053, 80061, 84443, 85025) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) (CPT code 71271), for the enrollee.
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee has nodules and history of smoking, and you want to make sure they are not growing. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. We reviewed the file and the Medicare rules. We find that the enrollee does not meet the following criteria--age greater than 77 and the presence of lung nodules.. Therefore, we decided that the Plan does not have to pre-
approve computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) (CPT code 71271), for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the orthopedic office visit, x-ray, and arthrocentesis services you received on February 22, 2021.
You asked the Plan to waive the deductible for the medical services. You say that you cannot afford these services and you feel as though the Plan routinely denies your care. The Plan denied your request. The Plan says you had not yet met your annual deductible when you received these services. The Plan says that it has waived the $3.07 charge for this date and only assessing the $203 annual deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 annual deductible for all medical services except for preventive services, Part B drugs, diabetic supplies, emergency room visits, emergency ambulance, urgent care, applicable rides, renal care, and lab services. You had not yet met this $203 deductible before receiving these services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 annual deductible for all medical services except
for preventive services, Part B drugs, diabetic supplies, emergency room visits, emergency ambulance, urgent care, applicable rides, renal care, and lab services. This cost sharing is a contractual obligation that had not been met at the time the medical services was received on February 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the orthopedic office visit, x-ray, and arthrocentesis services you received on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a shoe insert with longitudinal arch provided on April 27, 2021.
You asked the Plan to waive the coinsurance for a shoe insert with longitudinal arch. You say that you were never fitted for the shoe insert. 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 20% coinsurance for prosthetic devices and related supplies. You received a shoe insert with longitudinal arch on April 27, 2021. The total allowed amount is $317.53 and 20% of that is $63.50.
You have been asked to pay the total coinsurance amount of $63.50 for a shoe insert with longitudinal arch. A shoe insert with longitudinal arch falls within the prosthetic devices and related 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 coinsurance for a shoe insert with longitudinal arch provided on April 27, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital services you received from March 13, 2021, to March 18, 2021, and the computed tomography (CT) scan of the chest you had on April 13, 2020.
You asked the Plan to waive the copayments for the inpatient hospital services and the CT scan. You say that when you enrolled in this plan, you were signed up for the wrong plan. You stated that you were signed up for a plan that didn't work with your supplemental insurance. You stated that this Plan has since been cancelled, but you would like the copayments waived. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the CT scan, since the allowed amount for this service ($175.45) is less than your copayment obligation, you are responsible for the full allowed 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 per day for days 1-5 for inpatient hospital care. You have been asked to pay a $295 copayment per day for days 1-5 for the inpatient hospital services and a $180 copayment for the CT scan. The CT scan falls within the advanced imaging services benefit category. This means that you have been asked to pay the correct amounts 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 the inpatient hospital services you received from March 13, 2021, to March 18, 2021, and the computed tomography (CT) scan of the chest you had on April 13, 2020.
Your complaint about which plan you were enrolled is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic ultrasound you had on April 26, 2021.
You asked the Plan to waive the copayment for the ophthalmic ultrasound. You say that you do not believe you should have to pay a separate copayment for this test. You say that it should be considered a normal test done as part of your office visit. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this test ($14.03) is less than your copayment obligation, you are responsible for the full allowed 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 $45 copayment for x-rays and ultrasounds. You have been asked to pay a $45 copayment for the ophthalmic ultrasound. Your Evidence of Coverage does not state that diagnostic testing is included as part of your office visit copayment. 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 ophthalmic ultrasound you had on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (K0553).
You asked the Plan to preapprove the continuous glucose monitor. You say that the device is required. The Plan denied your request. The Plan says you do not meet coverage criteria for the 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 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 the enrollee does 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 continuous glucose monitor (K0553).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received on April 13, 2021.
You asked the Plan to waive the coinsurance for the lab services. You say that you believe these lab services were part of your annual physical, so there should be no copayment. The Plan denied your request. The Plan says you were charged this coinsurance correctly because these lab services were not billed as routine blood work. The Plan also says that you are not responsible for the charges for code 85027.
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 20% coinsurance for all other outpatient lab services except routine blood work. You have been asked to pay 20% coinsurance for the lab services. The medical records show that the lab services were ordered as part of your assessment for memory loss, not as a routine matter. That is why the coinsurance applies. 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 coinsurance for lab services you received on April 13, 2021.