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

We decided that the Plan has to pay for lab services (cardiovascular risk assessment) provided to the enrollee on September 23, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says that Medicare Guidance says Medicare denies coverage for all cardiovascular-respiratory risk assessment panels based on the following: Medicare Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk Assessment (L36139 and L36523), Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), and Medicare Local Coverage Determination: MolDX: Biomarkers in Cardiovascular Risk (L36129).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. In this case, the decision was overturned administratively as the Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The regulations referenced by the Plan are not in the MAC B coverage jurisdiction for the enrollee's state of Arizona or the provider location of Colorado and do not apply in this case. The Plan has not substantiated its denial. Therefore, we decided that the Plan has to pay for lab services (cardiovascular risk assessment) provided to the enrollee on September 23, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on March 16, 2021.
You asked the Plan to waive the copayment for podiatry services. You say that you feel that the services do not warrant a copayment. The Plan denied your request. The Plan says 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 clearly says that you must pay a $30 copayment for podiatry services. You have been asked to pay a $30 copayment for podiatry services. Podiatry services fall within the podiatry services 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 copayment for podiatry services provided on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services beyond July 23, 2021.
You asked the Plan to pre-approve SNF services. You say that continuation of SNF services is medically necessary. The Plan denied your request. The Plan says continuation of SNF services 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 services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, you no longer qualify for SNF coverage. You do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a
maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial
and, as a practical matter, can be provided at a lower level of care (ex. home, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued SNF services beyond July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve male vacuum erection system (L7900).
You asked the Plan to pre-approve the male vacuum erection system. You say that you have a serious side effect when taking the medications for erectile dysfunction. This device would help your quality of life and improve partner intimacy. The Plan denied your request. The Plan says this device is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the male vacuum erection system have not been met. Therefore, we decided that the Plan does not have to pre-approve male vacuum erection system (L7900).
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 an IRF is medically necessary in this case. The Plan denied your request. The Plan says the records show that it is not reasonable to expect that this enrollee will be able to fully benefit from the intensity of services of an IRF. The necessary services can safely be provided at another level of care.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230) provided on March 29, 2021.

You asked the Plan to pay for an intraoral periapical radiographic image. You say that you want the Plan to pay for this service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230) provided on March 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT visits are medically
necessary. The Plan denied your request. The Plan says additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 ten (10) additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. 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 of twenty-one (21) outpatient visits 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 has been instructed in and is compliant 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 ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on October 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab services provided on October 12, 2020 by an out of network (OON) provider.
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 you are unable to walk or stand up on your own. You say that you had a previous stroke and can only use one arm and one leg. The Plan denied your request. The Plan says the records provided have not demonstrated a complexity of nursing, medical, and rehabilitation needs that require an IRF stay with an interdisciplinary approach to rehabilitation care. The Plan says that there is no reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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 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 a pneumatic compression device (E0652) and segmental
pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are the
manufacturer and only supplier of the Flexitouch pneumatic compression device. The Plan denied your request.
The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no
failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
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 segmental pneumatic appliance (E0667).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 7, 2020, to December 11, 2020.

You asked the Plan to pay for the self-administered drugs. You say that your prescription coverage changed in January 2021. You also say that your change in insurance provider may have created an issue in the payment being made. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received not covered under Medicare Part B.

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 pay for the self-administered drugs provided from December 7, 2020, to December 11, 2020.

Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 20, 2019 by an out
of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician.

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 physician services provided on December 20,
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex procedure.
You asked the Plan to pre-approve the Coflex procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the requested Coflex procedure is 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 Coflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Coflex device is experimental. High failure rates with similar devices have been reported. More research is needed before coverage can be considered.
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 Coflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex procedure
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you will progress well in a skilled nursing facility. The Plan denied your request. The Plan says that your clinical condition does not require skilled nursing care as an inpatient.
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 your 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery.
You asked the Plan to pre-approve back surgery. You say that the enrollee has tried various conservative
modalities and has a progressive spondylosis on imaging. The Plan denied your request. The Plan says the
requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the requested services are only covered when the
enrollee is enrolled in a clinical study.
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in a
clinical study. Based on this information, we decided that Medicare rules for coverage of back surgery have not
been met. Therefore, we decided that the Plan does not have to pre-approve back surgery.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 12, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you have only ever owed $25 for ultrasounds in the past and do not understand why the Plan has not paid anything toward the claim. The Plan denied your request. The Plan says 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 clearly says that you must pay a $100 copayment for ultrasounds. You have been asked to pay the allowed amount of $91.44, which is less than the $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for an ultrasound provided on January 12, 2021.