Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482)
provided to the enrollee on November 3, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 80307 and Current Procedural Terminology (CPT)
code 80307 remain not supported. remains not supported.

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 code 80307 and HCPCS G0482 is not supported in the medical record. Specifically, the
place of service on the CMS-1500 form must reflect the location of the patient when the specimen was
obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of
place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug
testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0012) to be provided by an out of network provider.

You asked the Plan to pre-approve a power wheelchair. You say that you need the requested wheelchair. The Plan denied your request. The Plan says rules for out of network care have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0012) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and pneumatic appliance. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) and an occlusal guard
(D9944).

You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan
denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan says that
occlusal guard 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
porcelain crown (D2740) and an occlusal guard (D9944).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the continued SNF services. You say that the records provided support the
need for continued SNF care. The Plan denied your request. The Plan says the enrollee does not meet the
guidelines for coverage of continued SNF care. The Plan says that the enrollee does not have any skilled
therapy or skilled nursing service needs.

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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 the continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device.

You asked the Plan to pre-approve the Vertiflex Superion interspinous device. 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 Vertiflex Superion interspinous
device. Our reviewer says that the requested services are not considered medically reasonable and necessary in
this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to
show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Vertiflex Superion interspinous device have not been met. Therefore, we
decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the requested item is not for convenience but a medical necessity. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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 SNF care is medically necessary. The Plan denied
your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 patient was admitted to an acute care hospital for urinary tract infection,
pneumonia, anemia and removal of a bladder tumor. Medical conditions are stable. There are no complex
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that the requested items are a medical
necessity for you. The Plan denied your request. The Plan says rules for compression stockings have not been
met.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifty (50) additional routine transportation trips.

You asked the Plan to pre-approve fifty (50) additional routine transportation trips. You say that you require transportation to appointments. The Plan denied your request. The Plan says that the requested amount exceeds the limit listed by the plan.

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 a maximum of fifty-two (52) trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover routine transportation over the benefit maximum of fifty-two (52) routine transportation per year. Therefore, we decided that the Plan does not have to pre-approve fifty (50) additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy-duty wheeled walker to be provided by an out-of-network provider.

You asked the Plan to pre-approve the heavy-duty wheeled walker. You say that you need to be able to get around and a standard walker is not a good fit for you. The Plan denied your request. The Plan says this walker is not available in-network, but an equivalent heavy-duty walker was approved.

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 a similar item at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the heavy-duty wheeled walker to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) and a consultation (D9310) to be performed by an oral surgeon.

You asked the Plan to pre-approve the dental services. You say that you are in pain. You say that you need your teeth extracted. You also say that this is why you have insurance. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist in order to be covered. The Plan also says that dental services to be performed by an oral surgeon are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental services must be performed by a participating general dentist in order to be covered. Therefore, we decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) and a consultation (D9310) to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor (A9276).

You asked the Plan to pre-approve the continuous glucose monitor sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Insufficient documentation was provided to support the request. No medical records or clinical documentation was provided to support the requested item. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve pneumatic compression device. You say that this requested item is medically necessary. The Plan denied your request. The Plan says comparable services are available in-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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device (E0651) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve saline solution.

You asked the Plan to pre-approve saline solution. You say that you need saline solution for wound care. The
Plan denied your request. The Plan says saline solution is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say for any item to be covered by Medicare, it must 1) be
eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment
of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable
Medicare statutory and regulatory requirements.

We looked at the file and Medicare rules. Saline solution is statutorily non-covered. Based on this information,
we decided that Medicare rules for coverage of saline solution have not been met. Therefore, we decided that
the Plan does not have to pre-approve saline solution.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you have an infection and need to go to rehab. The Plan denied your request. The Plan says you do not require an intensive and coordinated interdisciplinary approach to rehab.

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 physician reviewer found that you were admitted to the acute care hospital for surgical treatment of hidradenitis suppurativa. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repair of nasal valve collapse using the Latera implant for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this procedure is considered experimental and investigational.

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 pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with nasal valve collapse based on her symptoms and her clinical exam. It states her breathing improved with nasal cones. The literature looking at the effect of the Latera implant includes 1 RCT and 2 cohort studies. There was a statistically significant improvement in response to the implant. Even though there are no studies looking at effects past 24 months, so far, the results after Latera implant placement appears to be promising. As time goes on, more studies can be done to look at the long-term effects. The clinical exam supports the diagnosis of internal nasal valve collapse, and there is literature supporting the use of Latera to treat this collapse.

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 services have been met. Therefore, we decided that the Plan has to pre-approve repair of nasal valve collapse using the Latera implant for the enrollee.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and drug testing services provided on June 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that you requested enrollment with the plan. The Plan denied your request. The Plan says prior authorization was not obtained.

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 file shows that the enrollee was seen for a follow-up visit. 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 office visit and drug testing services provided on June 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued BiLevel Positive Airway Pressure (BiPAP)
therapy.

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 medically necessary.

The Plan must follow Medicare rules. Medicare rules say that continued BiPAP therapy is covered when
specific criteria are met.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have
obstructive sleep apnea (OSA) and are being treated with BiPAP. The start date of the treatment is unclear.
There is no evidence of a follow-up visit to assess the effectiveness of the BiPAP therapy. The usage report
does not show consistent use of the device. The Medicare criteria for coverage of continued therapy are not met
and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued BiLevel Positive Airway Pressure (BiPAP) therapy.