Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided September 13, 2019.You asked the Plan to pay for the surgical extraction. You say that you are appealing the services rendered by your oral surgeon.The Plan denied your request. The Plan says this service is not covered under the plan benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) provided September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forsupply allowance for therapeutic continuous glucose(K0553) provided September 15, 2019.You asked the Plan to pay forsupply allowance for therapeutic continuous glucose. You say that please review the attached records again as they do support medical necessity per Medicare guidelines.The Plan denied your request. The Plan says the medical records submitted appear to have been altered, there is no evidence of an established relationship between the enrollee and the ordering physician, here was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health ProfessionalShortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare programand cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forsupply allowance for therapeutic continuous glucose (K0553) provided September 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested continuation of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 continued skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found from a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a minimal to maximal assist level with functional mobility including gait to a few steps with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued skilled nursing facility (SNF) care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has a history of hypoglycemia unawareness and requires a CGM to be aware of changes in blood glucose as well as adjusting insulin doses. The Plan denied your request. The Plan says there is no supportive evidence of frequent adjustment of insulin on the basis of blood glucose monitor testing results or hypoglycemia unawareness.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The medical record does not show frequent adjustment of the enrollee's insulin regimen. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ambulance transportation. You say that this was an emergency transport and the enrollee needed to be transported to another hospital because the original hospital did not have certain services that the enrollee needed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 has network providers available who can provide 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 ambulance transportation provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for SNF services.
You asked the Plan to pre-approve the SNF services. You say that you are weak and unable to leave your bed and you need SNF care. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. You received antibiotics and diuretics. Regarding rehabilitation services, you received physical therapy and occupational therapy in the acute hospital. You were at minimal to maximal assist with functional mobility and varying assist with activities of daily living. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve the Orthovisc. You say that you would like reconsideration as these injections have been helpful in the past. The Plan denied your request. The Plan says there is no clinical use for this treatment and evidence does not clearly show treatment is beneficial.
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 Orthovisc. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found viscosupplementation has not been shown to be superior to placebo injections. 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical extraction (D7210) intravenous sedation (D9239 and
D9243) provided August 13, 2019.
You asked the Plan to pay for the dental services. You say that you went to this provider due to being in
extreme pain and they refused to code services as incomplete extractions. You had to go to a dental surgeon to
get the rest of the tooth out. The Plan denied your request. The Plan says this services are not covered benefits
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for surgical
extraction (D7210) intravenous sedation (D9239 and D9243) provided August 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/21/20 for the treatment of generalized weakness related to decompensated cirrhosis. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He underwent paracentesis and was treated with diuretics for ascites. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a modified independent to stand by assist level with functional mobility including gait to 200 feet x 3 with no assistive device. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
You asked the Plan to pre-approve a replacement power mobility device. You say that your power wheelchair is very uncomfortable. The Plan denied your request. The Plan says your current power wheelchair, purchased in January 2017, is still under reasonable useful lifetime and was repaired.
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. Your PMD is still within the 5-year RUL and the documentation submitted does not show that your PMD is irreparably worn, irreparably damaged, or that you have had a change in medical condition to warrant the scooter at issue. Based on the records provided, there is no indication that a replacement PMD meets Medicare coverage criteria. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.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 preapprove a pneumatic compression device (E0652)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation greater than 60 miles for the 2020 calendar year.
You asked the Plan to pre-approve the routine transportation greater than 60 miles. You say that you need to see a particular specialist in Pittsburgh, PA that knows your case and your medical history and you are not able to see anyone else. The Plan denied your request. The Plan says each one-way trip must not exceed 60 miles based on the most efficient route.
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. We looked at your request, the records in the case file, and the rules. The file shows that the Plan offers a supplemental routine transportation benefit, which allows for coverage of 50 one-way trips and each one-way trip must not exceed 60 miles. The provider you want to see in Pittsburgh, PA is located beyond the Plan's 60-mile radius. Therefore, we decided that the Plan does not have to pre-approve routine transportation greater than 60 miles for the 2020 calendar year.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on April 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for pathology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 has network providers available who can provide 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 pathology services provided on April 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe continuous passive motion device provided from June 21, 2019 to July 9, 2019.You asked the Plan to waive the coinsurance forthe continuous knee exerciser. You say that a nurse told you that you would not have to pay for the continuous knee exerciser.The Plandenied your request. The Plan says the continuous knee exerciseris covered and you were charged the coinsurance 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the continuous knee exerciser. the continuous knee exerciser falls within the durable medical equipment and related supplies 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 coinsurance forthe continuous passive motion device provided from June 21, 2019 to July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on July 1, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on July 1, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for an X-ray provided on September 22, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you should owe a $0 copayment for the X-ray. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct 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 does not say in clear and accurate terms how much you should expect to pay for X-rays provided by a specialist. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $30.29 copayment for X-rays provided by a specialist. The Plan contract does not clearly say how much enrollees must pay for X-rays provided by a specialist. 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 copayment for an X-ray provided on September 22, 2019.
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 Rituxan for the enrollee.
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Rituxan. Our reviewer says that Rituxan is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Remicade or Inflectra; and Simponi Aria or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Rituxan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.