Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an implantable cardiac monitor (33285).
You asked the Plan to pre-approve the implantable cardiac monitor. You say that the cardiac monitoring is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that implantable cardiac loop recorders are covered when 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 implantable cardiac monitor. Our reviewer says that the requested procedure is medically necessary. Our physician reviewer found the patient has a history of cryptogenic stroke which has not been adequately evaluated specifically for the presence of paroxysmal atrial fibrillation as the cause. There is echocardiographic evidence of hypertrophic cardiovascular disease. The enrollee meets medical necessity criteria for evaluation for occult atrial fibrillation and based on the co-morbid condition of intractable and frequent seizures, an implantable cardiac loop recorder would be an appropriate and reasonable method for further evaluation. 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 implantable cardiac monitor have been met. Therefore, we decided that the Plan has to pre-approve an implantable cardiac monitor (33285).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth (osteogenesis) stimulator (E0760).
You asked the Plan to pre-approve a bone growth stimulator. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a bone growth stimulator have not been met.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve a bone growth (osteogenesis) stimulator (E0760).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete dentures (D5110 and D5120).

You asked the Plan to pre-approve complete dentures. You say that the service is medically necessary. The
Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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. Specifically, records indicated you received these services on August
14, 2019. This means you have already exhausted this benefit. Therefore, we decided that the Plan does not
have to pre-approve the complete dentures (D5110 and D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic lumbar sacral orthosis (TLSO) rendered on April 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the thoracic lumbar sacral orthosis (TLSO) rendered on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient clinic visit, and the wound care provided from February 19, 2021, to March 12, 2021.
You asked the Plan to reduce the copayment for the outpatient clinic visit and the wound care. You say that you were told you would have a $20 copayment for the services. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per visit for Medicare-covered outpatient surgery or procedure at a hospital facility.
You have been asked to pay a total of $225 for the outpatient clinic visit and the wound care. The outpatient
clinic visit, and the wound care fall within the "Outpatient hospital services" benefit category. See chart below.
Date of Service Service Allowed Amount Copayment Member Liability
February 19, 2021 Outpatient clinic
visit
$117.74 $225 $0 - This is less
than the standard
copayment amount.
March 12, 2021 Wound care $324.49 $225 $225
Total $225
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 reduce the copayment for the outpatient clinic visit, and the wound care provided
from February 19, 2021, to March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Stabilink device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies do not show that this device is more helpful than traditional devices.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. The provided records do not indicate that the requested device is being used as a supplementation fixation device. The elements of the coverage rule are not satisfied. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Stabilink device.
Appeal type: Drugs
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for Part B drug and injection service. You say that you do not feel that the Plan is being nice about it. The Plan says that the cost-sharing amounts you are being charged are correct.
We decided that the Plan has to waive the cost-sharing for injection service (procedural code 96372 and hospital revenue code 0260).
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 does not say in clear and accurate terms how much you should expect to pay for an injection administration service. The Plan applied the outpatient hospital surgery copayment to this service; however, an injection administration service is not considered to be surgery. Therefore, the outpatient hospital surgery copayment does not apply to this claim.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay $325 copayment for injection administration service. The Plan contract does not clearly say how much enrollees must pay for an injection administration service in an outpatient hospital. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost-sharing for injection service.
We also decided that the Plan does not have to waive the cost-sharing for Part B drug (procedural code J0897 and hospital revenue code 0636).
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 20% coinsurance for Part B drugs. The allowed amount of this drug is $899.70, resulting in a coinsurance amount of $179.94. Therefore, we decided that the Plan does not have to waive the cost-sharing for Part B drug.
Therefore, we decided that the Plan has to reduce your cost-sharing amount for this claim from $241.83 to $179.94.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the step therapy criteria have not been met because the enrollee has not tried Orthovisc or Synvisc.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Euflexxa. Our reviewer says that without the support of the documentation, Euflexxa is not approved as step criteria have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc or Monovisc. Step therapy, as outlined by the plan, requires that one of these be trialed first. Our reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy; in the home, per diem (S9131) rendered by the OON provider on November 18, 2020, and November 21, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 physical therapy; in the home, per diem (S9131) rendered by the OON provider on November 18, 2020, and November 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient is stable with no new medical problems, has no nursing needs and is at high functional level, and does not need daily skilled therapies. 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 care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0150, D0330, and D1110) provided on February 15, 2021.

You asked the Plan to pay for dental codes D0150, D0330, and D1110. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dental services provided are not covered when provided by a non-participating provider.

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 provided by a non-participating provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services (D0150, D0330, and D1110) provided on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on
March 4, 2020.

You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered as 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 code 97110 is not supported in the medical record. Specifically, the records indicate that the
services were performed by a physical therapist assistant in a home health or hospice setting. There is a more
appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan
does not have to pay for the therapy services represented by code 97110 provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4342) provided on February 4, 2021.

You asked the Plan to pay for dental code D4342. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D4342 is not covered under the Plan's supplemental dental 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, dental code D4342 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planning (D4342) provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting, such as a skilled nursing facility.
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 based on the medical records provided, the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require an intensive therapy program. Due to your reported level of fatigue and decreased endurance, care at the skilled nursing facility level appears to be appropriate in this case.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled therapy or skilled nursing needs. 

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 care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transport and the inpatient
hospital admission provided from February 16, 2021, to February 24, 2021.

You asked the Plan to waive the copayments for the ambulance ride and the inpatient hospital admission. You
say that you are appealing the copayments for these two claims. The Plan denied your request. The Plan says
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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for each one-way Medicare-covered ambulance transport a $350 copayment per day, days 1-5 for each in-network Medicare-covered hospital admission/stay and a $0 copayment for additional hospital days. 

You have been asked to pay a $275 copayment for the ambulance ride and a $350 copayment per day, days 1-5, for the inpatient hospital admission. ($350 x 5 = $1,750). The ambulance ride falls within the "Ambulance services" benefit category. The inpatient hospital admission falls within the "Inpatient hospital care" 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 copayments for the ambulance transport and the inpatient hospital admission provided from February 16, 2021, to February 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on September 17, 2020.

You asked the Plan to pay for occupational therapy. The Plan denied your request. The Plan says no new medical records were provided. The documentation submitted on appeal consists of duplicate records previously reviewed.

The Plan must follow Medicare rules. Medicare rules say the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. The file shows that the occupational therapy was billed by a nurse practitioner. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy provided on September 17, 2020.