Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on May 21, 2020 to March 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the provider's office told you they were in-network with your plan. The Plan denied your request. The Plan says the services were not considered urgent or emergent.
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 pain management services provided on May 21, 2020 to March 4, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of residual tooth roots (D7250), and a bone replacement graft (D7953) provided on January 8, 2021.
You asked the Plan to pay for removal of residual tooth roots, and a bone replacement graft. You say that the services at issue should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 pay for removal of residual tooth roots (D7250), and a bone replacement graft (D7953) provided on January 8, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental bone removal and anesthesia (codes D7472, D9222, D9223, and D9612).

You asked the Plan to pre-approve dental services. You say that your bone hurts and needs to come out. The Plan denied your request. The Plan says these services are not covered by the Plan's dental benefits.

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 dental bone removal and anesthesia (codes D7472, D9222, D9223, and D9612).
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the durable medical equipment provided on February 11, 2021.
You asked the Plan to waive the cost share for the services provided. You say that you cannot afford the expense. The Plan denied your request. The Plan says the claim processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment. The enrollee has been asked to pay a 20% coinsurance for the services provided. The services fall within the durable medical equipment benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the durable medical equipment provided on February 11, 2021.
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 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 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 the enrollee's medical conditions are stable and they do not have any complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the end-stage renal disease (ESRD) services provided January 3, 2021, to January 29, 2021.

You asked the Plan to pay for the ESRD services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says that required modifier for ESRD services is missing or invalid.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, we have insufficient information to decide this case. It is unclear what codes require a modifier, what modifier is required, or why this modifier is required. Therefore, we decided that the Plan has to pay for the end-stage renal disease (ESRD) services provided January 3, 2021, to January 29, 2021.

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 the lumbar orthosis provided on November 6, 2020.

You asked the Plan to pay for the orthosis. You say that the Plan failed to pay the bill. The Plan denied your request. The Plan says the reasonableness of the durable medical equipment has not been established.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding this item. The records do not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on November 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on December 21, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Original Medicare is still responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on December 9, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital services provided on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108x2, E2300, E2311, E2313, E2377) for the enrollee.
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 services 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 with a joystick and 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 with the ability to dress, bathe, an feed himself supports that the enrollee can control any power options through their own individual switches. The E2300 seat elevator, a K0108 color kit mossy oak and K0108 F3 hub cap color mossy oak are not primarily medical in nature and therefore not medically 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108x2, E2300, E2311, E2313, E2377) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide two routine transportation trips with additional mileage.
You asked the Plan to provide additional mileage. You say that you need this transportation to get to your appointment. The Plan denied your request. The Plan says the requested doctor's office is more than 50 miles away. Trips that exceed the Plan's 50-mile limit are not covered. Additional mileage is not covered by this benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the trip is within 50 miles and to a Plan-approved location.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the requested
destination is more than 50 miles away. Therefore, we decided that the Plan does not have to provide two
routine transportation trips with additional mileage.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this was recommended for unsteady gait. The Plan denied your request. The Plan says there is no evidence that a cane or walker would not be able to assist with mobility.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found it is not clear that the enrollee's mobility deficit limits participation in specific MRADLs in the home.

There is no detailed neuromuscular examination of the enrollee or gait evaluation indicating this abnormality is unable to be helped by the use of a walker, cane, or manual wheelchair. There is no detailed evaluation of the home indicating the enrollee cannot safely operate a power mobility device 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says an intensive rehab program 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 you do not require the intensity of services available at the IRF. Specifically, you are not shown to require 15 hours per week of rehab services and regular physician evaluation. Your care needs
can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 22, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this item was not medically reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that a lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there insufficient documentation of a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
March 23, 2021, through March 26, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says based on clinical information the enrollee does not meet medical necessity based on InterQual criteria.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department with epigastric pain, nausea, dry heaving, dizziness, and palpitations for three weeks. She admitted to alcohol use. Her vitals were stable. Her hemoglobin was 9.7, high alkaline phosphatase levels 592, and she was treated with Reglan, Tylenol, famotidine, and fluids and was admitted for symptomatic anemia and possible alcohol gastritis. The enrollee did not have signs or symptoms suggestive of active bleeding and anemia and was not severe enough to warrant an inpatient admission. There were no signs of severe alcohol withdrawal or other acute conditions to suggest the enrollee would need hospital services that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 23, 2021, through
March 26, 2021.