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

We decided that the Plan does not have to pre-approve acupuncture.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the enrollee has a diagnosis of migraine cephalgia and no diagnosis of chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair and lift mechanism.
You asked the Plan to pre-approve the requested items. You say that when you sit, you can feel the springs. The Plan denied your request. The Plan says a home reclining chair is a convenience item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.
We looked at the file and the rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers.
The file shows that you have a seat lift mechanism for your chair. The records provided do not show that the current seat lift mechanism is damaged or beyond repair. Your current lift mechanism serves the same purpose as the requested item. Based on this information, we decided that the Medicare rules for coverage have not been me.t Therefore, we decided that the Plan does not have to pre-approve a recliner chair and lift mechanism.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on September 16, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you should not be responsible for the transport copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $250 for these services. 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 ambulance services provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120), a complete upper denture (D5110), and an extraction (D7140) for tooth # 7.
You asked the Plan to pre-approve the dental services. You say that you need these services to be approved. The Plan denied your request. The Plan says complete dentures are not listed as covered services. The Plan says that extraction is not listed as a covered service either.
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 complete lower denture (D5120), a complete upper denture (D5110), and an extraction (D7140) for tooth # 7.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study (93971) rendered by an out of network (OON) provider on August 13, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the extremity study (93971) rendered by an out of network (OON) provider on
August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the requested device. You say that having a scooter will allow you to have a better quality of life. The Plan denied your request. The Plan says the requested item does not follow coverage guidelines.
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. The file does not show that your condition cannot be improved by a manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the provision of testing materials for at-home anti-coagulant INR testing provided on December 14, 2020.

You asked the Plan to reduce the copayment for the provision of testing material for at-home INR testing. You say that you should have been charged 20% coinsurance for durable medical equipment as opposed to a $45 copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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 enrollees must pay 20% coinsurance for medical supplies. 

The Plan says you must pay a $45 copayment for the provision of testing material for at-home INR testing. Based on the Plan contract, however, you cannot be asked to pay more than $18.46 which is 20% of the allowed amount for the provision of testing material for at-home INR testing. The allowed amount is $92.30. ($92.30 x 20% = $18.46). The record shows the for code G0249 is considered a medical supply. Therefore, we decided that the Plan has to reduce the copayment for the provision of testing materials for at-home anti-coagulant INR testing provided on December 14, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds (E0303) and trapeze equipment (E0910).
You asked the Plan to pre-approve the hospital bed and trapeze equipment. You say that you are unable to turn in bed and has to lay flat. You get pressure sores because you have to lay one way on your bed. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested items as the
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or
4. The patient requires traction equipment, which can only be attached to a hospital bed. We looked at the file and Medicare rules. The records show that the enrollee weighs 310 pounds. The requested hospital bed is for weight 350 to 600 pounds. The standard trapeze equipment is for weight up to 250 pounds. Based on this information, we decided that Medicare rules for coverage of the hospital bed and trapeze equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds (E0303) and trapeze equipment (E0910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve these services. 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 a power seat elevation feature (E2300) is non-covered. We looked at the file and Medicare rules. The requested services are not covered by Medicare because they do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are contracted providers and facilities in the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion 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 Gel-One.
You asked the Plan to pre-approve Gel-One. You say that you would like reconsideration because this shot is needed as far as your health is concerned. The Plan denied your request. The Plan says for this drug to be covered under your medical benefit, it must be supplied by your medical provider or facility.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Benefits for Gel-One 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug tests (80348, 80354, 80358, 80372, 80361, 80363, 80365, 80367, 80373)
You asked the Plan to pay for drug tests. You say that these tests should be covered. The Plan denied your request. The Plan says these tests were 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. We find that CPT codes 80348, 80354, 80358, 80372, 80361, 80363, 80365, 80367, and 80373 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug tests (80348, 80354, 80358, 80372, 80361, 80363, 80365, 80367, 80373)
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for the Covid-19 testing received on November 16, 2020 minus any cost share requirements.
You asked the Plan to hold you harmless for the Covid-19 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You received the Covid-19 testing by a contract provider. The file does not show that the Plan provided notice that the Covid-19 testing would not be covered. Under Medicare rules, this means the Covid-19 testing is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the Covid-19 testing received on November 16, 2020 minus any cost share requirements.
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: Unfavorable

We decided that the Plan does not have to pre-approve electron beam computed tomography (CT) for calcium
scoring (S8092).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the
enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that this
service is not medically necessary. Our physician reviewer found that the enrollee has hyperlipidemia but was
intolerant of all statin medications. The CT calcium scoring was requested to further risk stratify to see if the
enrollee would be a candidate for PCSK-9 inhibitors. The enrollee already meets criteria for consideration for
use of PCSK-9 inhibitors based on her significantly high low-density lipoprotein (LDL) and is already a high
risk. She does not need any additional testing to further risk stratify. Therefore, this request for CT calcium
scoring will be considered not medically necessary for this 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 this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve electron beam computed tomography (CT) for calcium scoring (S8092).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0482) provided August 14, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 80307, & G0482 are not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service described in the records (57, rehabilitation facility). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0482) provided August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Wig, any type (A9282).
You asked the Plan to pre-approve the wig. You say that you feel that this should be covered because you are receiving chemotherapy and losing hair. You feel that this should be an acceptable reason for a female to have a wig as a result of treatment. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve Wig, any type (A9282).
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 enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a small bowel obstruction. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a permanent spinal cord stimulator.
You asked the Plan to pre-approve spinal cord stimulator. You say that your spinal cord stimulators were removed and you need to have them back. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you already have a permanent spinal cord stimulator which was placed in October 2020.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers one permanent spinal cord stimulator per patient per lifetime. We looked at the file and Medicare rules. You have already received one permanent spinal cord stimulator, therefore Medicare does not cover an additional spinal cord stimulator. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a permanent spinal cord stimulator.