Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing services and physical therapy.
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan denied your request. The Plan says that you have limited mobility, have impaired cognition and refuse care from the provider. The Plan says that there are no skilled services being provided. The Plan also says that you have received extensive education and have the necessary equipment at home including a walker and hospital bed.
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 the home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The reviewer found that you do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the requested services 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing services and physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the form-fitting conductive garment for use with an electrical stimulation device billed with date of service (DOS) October 6, 2020.
You asked the Plan to pay for the conductive garment as billed. You say that the documentation has all the necessary elements to allow payment for this item. The Plan denied your request. The Plan says the documentation does not support the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that for suppliers who use a shipping service, the invoice identifying the item must be linked in some way to the POD. The DOS reported can either be reported as the date the item was originally shipped or the date it is delivered to the enrollee. Review of the file shows that the date of delivery was October 13, 2020 which does not match the DOS. The supplier could report the date of shipping instead; however, there is no evidence of when the item was shipped. This is not included on the delivery confirmation nor is the packing slip dated. There is also nothing which links the packing slip to the delivery confirmation. As such, we find that the POD is not valid and the date of service is incorrectly reported. Therefore, we decided that the Plan does not have to pay for the form-fitting conductive garment for use with an electrical stimulation device billed with date of service (DOS) October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction.
You asked the Plan to pay for the tooth extraction. You say that the extraction was medically necessary. The Plan denied your request. The Plan says that tooth extraction is not a covered 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 pay for the tooth extraction.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this device is experimental.
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 Vertiflex Superion Spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 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 Vertiflex Superion Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued occupational therapy services.
You asked the Plan to pre-approve continued occupational therapy services. You say that you need continued therapy. The Plan denied your request. The Plan says the records do not indicate ongoing medical necessity.
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 continued occupational therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are still required to safely and effectively provide treatment. You have been instructed in safety and a home exercise program and the requested services are not part of a maintenance 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 continued occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on September 1, 2020.
You asked the Plan to pay for the vaccine. You say that you provider recommended the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on September 1, 2020.
Benefits for the vaccine 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: Favorable

We decided that the Plan has to pay for the cleaning (D1110) provided on December 15, 2020.
You asked the Plan to pay for the dental service. You say that you went to see your dentist for tooth pain. You say that you are unemployed. You say that you would like the Plan to waive your bill. You also say that you do not have any money to pay the dental bill. The Plan denied your request. The Plan says that 2 cleanings are covered per plan year. The Plan also says that the frequency limit for this service has been exceeded.
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. The Plan covers the dental service when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Although you received 2 cleanings in the year 2020 under your previous plan, your current plan has not provided any cleanings. Therefore, we decided that the Plan has to pay for the cleaning (D1110) provided on December 15, 2020.
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: Imaging
Decision: Favorable

We decided that the Plan has to waive the cost share for the diagnostic mammogram and the ultrasound provided on November 10, 2020.You asked the Plan to waive the cost share for the diagnostic mammogram and the ultrasound. You say that you were never told there would be a copayment. You say you would not have done the testing until you had the funds.The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount. 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. The Plan submitted an incorrect Evidence of Coverage. Therefore, we are unable to confirm if the cost sharing amount you are being asked to pay is correct. Therefore, we decided that the Plan has to waive the cost share for the diagnostic mammogram and the ultrasound provided on November 10, 2020.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. At the time of the request, the member's status is critical and unstable. The member is on pressors and is receiving medically necessary acute and/or critical care. 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on December 1, 2020, to December 28, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were never told of a copayment. You say that you cannot afford this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $40 copayment for physical therapy. The total amount you are being asked to pay is $240 ($40 x 6 sessions = $240). Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on December 1, 2020, to December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 7, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on October 6, 2020.
You asked the Plan to pay for the vaccine. You say that you were not told this would not be covered. The Plan denied your request. The Plan says this is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397).

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial
for payment. The Plan denied your request. The Plan says the record does not support the billed items in this
case.

The Plan follows Medicare rules. Medicare rules say that a knee immobilizer without joints, or a knee orthosis
with adjustable knee joints, or a knee orthosis, with an adjustable flexion and extension joint that provides both
medial-lateral and rotation control, are covered if the beneficiary has had recent injury to or a surgical
procedure on the knee. Additionally, knee orthoses are also covered for a beneficiary who is ambulatory and
has knee instability due to a condition specified in the LCD-related Policy Article.

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 these items. Our reviewer says that the
record does not support the medical necessity of the billed items in this case. Our physician reviewer found that
the enrollee's chief complaint was chronic pain located in the left and right knees. The documentation in the
case file does not support that the knee orthosis and suspension sleeve provided were medically reasonable and
necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is
insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible
objective documentation of joint laxity. Additionally, the suspension sleeve is not separately payable when the
base item is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not
have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 15, 2020.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not include medical records. Without records for the services in question, it cannot be confirmed that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on October 7, 2020.
You asked the Plan to pay for an LSO. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says there are no medical records to show the prescribing physician ever saw the enrollee.
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 pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and 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 an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on October 7, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the molecular profiling services (81450).

You asked the Plan to pay for the molecular profiling. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says that providers should use CPT code 81479 to bill comprehensive genomic profile testing.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the molecular profiling. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found several gene mutations have been identified among patients with Myelodysplastic syndrome (MDS) that may, in part, contribute to the clinical heterogeneity of the disease. Several genes affects prognosis and therapy decision making. Per the NCCN guidelines molecular profiling in patient's with MDS is a standard 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 the molecular profiling have been met. Therefore, we decided that the Plan has to pay for the molecular profiling services (81450).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.