Persius/hicric huggingface dataset:
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 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 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 the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 LTACH services have not been met. Specifically, the enrollee is receiving medically necessary services at their current level of care. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested service is considered an experimental/investigational 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an otolaryngologist (99245) to be
provided by an out of network (OON) provider.

You asked the Plan to pre-approve an office visit with a specialist. You say that the member would like further
evaluation of the member's condition and a second opinion from an out-of-network provider. The Plan denied
your request. The Plan says there are in-network providers available for these services.

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. The records provided for review do not
show that the services at issue are urgent or emergent. 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 an office
visit with an otolaryngologist (99245) to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.

You asked the Plan to pre-approve additional mileage. You say that the service should be covered. The Plan
denied your request. The Plan says the provider that the transportation is being requested to is 52 miles away
from your home each way; which is 2 miles over the limit of miles per your transportation benefit each way.

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 36 one-way trips and each one-way trip must not exceed 50 miles of
driving distance. trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven (7) additional home physical therapy (PT) visits.

You asked the Plan to pre-approve seven (7) additional home PT visits. You say that additional home PT is medically necessary. The Plan denied your request. The Plan says the records do not support the need for a skilled physical therapist to make more home visits.

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 seven (7) additional home PT visits. Our reviewer says that additional home PT is not medically necessary. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee is at a high functional level has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seven (7) additional home PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven (7) additional home PT visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the one-on-one health aide care provided from January 1, 2021, to January 31, 2021.

You asked the Plan to reimburse you for the home health aide services. You say that you were given 3 in network options for care. You say that upon calling them, they all had advised that none of them accepted Medicare. You say that the only option was to go out of network. You also say that the enrollee is totally dependent on others and cannot be left alone. The Plan denied your request. The Plan says the provider in this case is not certified for Medicare. The Plan also says that payment cannot be made to a provider that is not enrolled in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the one-on-one health aide care provided from January 1, 2021, to January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.

You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says you do not have a covered condition.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have certain mobility limitations.

The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gender confirmation genitalia surgery with an inpatient admission, represented by CPT code(s) 54520, 54125, 53430, 56805, 14041, and 57335.

You asked the Plan to pre-approve gender confirmation genitalia surgery with an inpatient admission. You say that the service is medically necessary. The Plan denied your request. The Plan says there is only documentation provided by one and not two mental health professionals and you do not have an established relationship with that health provider.

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 gender confirmation genitalia surgery with an inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not on hormone therapy and the record does not contain sufficient information of well documented dysphoria. Also, the several letters from your doctor's do not include medical records.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gender confirmation genitalia surgery with an inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve gender confirmation genitalia surgery with an inpatient admission, represented by CPT code(s) 54520, 54125, 53430, 56805, 14041, and 57335.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower partial denture (D5214) provided on March 10, 2021.

You asked the Plan to pay for a lower partial denture. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue 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 a lower partial denture (D5214) provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult dentition (D8090).

You asked the Plan to pre-approve the comprehensive orthodontic treatment of the adult dentition. You say that you would like this service to be covered under your plan because it is medically necessary for you to eat and get proper nutrition. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Elestrin 0.06% gel.

You asked the Plan to pre-approve Elestrin. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested drug is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Elestrin 0.06% gel.

Benefits for Elestrin 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy services coded 49650 provided on October 7, 2020.

You asked the Plan to pay for the laparoscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 49650 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy services coded 49650 provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor and appliance to be provided by an out-of-network provider.

You asked the Plan to pay for the pneumatic compressor and appliance. You say that the enrollee has medically necessary reasons for the prescribed pneumatic compression device and was unsuccessful at obtaining a pump from an in-network provider. You say that the coverage for the pump to treat the lymphedema should be authorized. The Plan denied your request. The Plan says in-network providers are available.

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the pneumatic compressor and appliance to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pulmonologist.

You asked the Plan to pre-approve these services. You say that the network providers cannot treat the enrollee's condition. The Plan denied your request. The Plan says the services are available from network providers.

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 confirmed that the network providers are able to treat the enrollee's diagnosis. 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 referral to an out-of-network pulmonologist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve the additional routine transportation. You say that you would like reconsideration because you have an appointment that cannot be missed. The Plan denied your request. The Plan says you have taken 24 out of the 24 covered one-way trips.

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 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin-based composite (D2331) for tooth #6.

You asked the Plan to pre-approve the resin-based composite. You say that you need another filling because you have gotten another hole in your tooth since your last filling. The Plan denied your request. The Plan says coverage for a filling for this tooth is not available until October of 2023.

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, fillings are limited to once per tooth every 48 months. The record shows that you received a resin-based composite (D2331) on tooth #6 on October 21, 2019 and your fillings benefit for tooth #6 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a resin-based composite (D2331) for tooth #6.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing for arsenic (82175), cadmium (82300), chromium (82495), ferritin (82728), glycosylated hemoglobin (83036), lead (83655), and mercury (83825) provided on June 19, 2020.

You asked the Plan to pay for testing for arsenic, cadmium, chromium, ferritin, glycosylated hemoglobin, lead, and mercury. You say that these services should be covered. The Plan denied your request. The Plan says these were screening services.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for testing for arsenic (82175), cadmium (82300), chromium (82495), ferritin (82728), glycosylated hemoglobin (83036), lead (83655), and mercury (83825) provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the crutches provided on November 27, 2020.

You asked the Plan to pay for the crutches. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code E0114 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the crutches have not been met. Therefore, we decided that the Plan does not have to pay for the crutches provided on November 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and coinsurance for initial hospital care and subsequent hospital care provided by the physicians on January 29, 2020, to February 6, 2020.

You asked the Plan to waive the deductible for an office visit and coinsurance for initial hospital care and subsequent hospital care. You say that you already paid these. The Plan denied your request. The Plan says the correct cost sharing amounts have 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 $290 deductible for an office visit and a 20% coinsurance for an outpatient surgery and other medical services/in-network. 

You have been asked to pay a $116.53 deductible for an office visit. You have been asked to pay a 20% coinsurance of the allowed amount for initial hospital care and subsequent hospital care.

Total Amount Being Asked to Pay: $116.53 + $29.97 + $13.22 = $159.72

An office visit falls within the physician/practitioner services/in-network benefit category, initial hospital care and subsequent hospital care falls within the outpatient surgery and other medical 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 deductible for an office visit and coinsurance for initial hospital care and subsequent hospital care provided by the physicians on January 29, 2020, to February 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.