Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that a review of the current medical literature indicates that this service is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, bioimpedance spectroscopy can be used to detect and prevent lymphedema. 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LAAC and inpatient admission.
You asked the Plan to pre-approve the LAAC and inpatient admission. You say that the enrollee is enrolled in a Food and Drug Administration (FDA) approved trial that is covered by Centers for Medicare and Medicaid Services (CMS) guidelines. The Plan denied your request. The Plan says the records do not show that the enrollee is unable to take blood thinners due to dangerous, life-threatening bleeding. The Plan also says that because the procedure requested is not medically necessary, the related inpatient hospital admission is also not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 LAAC and inpatient admission. Our reviewer says that the documentation does not support that the criteria for the LAAC and inpatient payment are met in this case. Our physician reviewer found that the records do not show that the member is unable to take blood thinners due to dangerous, life-threatening bleeding. 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 LAAC and inpatient admission have not been met. Please note, because the LAAC procedure does not meet criteria, inpatient admission is also not medically reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a LAAC and inpatient admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of an inpatient psychiatric hospital admission from August 12, 2021, forward.

You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that the continuation of inpatient mental health care is medically necessary, and outpatient services are insufficient for this enrollee's condition. The Plan denied your request. The Plan says the inpatient care was covered through August 11, 2021, but as of August 12, 2021, the enrollee is no longer an imminent danger to themselves or others and the necessary mental health care can be safely and effectively provided in a less intensive setting.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued inpatient psychiatric care. Our reviewer says that the inpatient mental health services are not medically necessary after the dates already approved by the health Plan. Our physician reviewer found that this enrollee was admitted to the acute inpatient psychiatric hospitalization on July 14, 2021 with severe, recurrent Major Depressive Disorder with psychosis. Based on the review of the provided records, it is not expected that this enrollee will improve in a reasonable period of time beyond the dates in question. At this point, the enrollee is not showing dangerousness to self or others, auditory or visual hallucinations, and they are without aggressive behaviors while not showing any acute threats of safety. The enrollee is cooperative and compliant with medication and current treatment. At this point, it does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than at a lower level based on the enrollee's current condition. This enrollee could be moved to a less intensive setting as of August 12, 2021, going forward and as of this date did not meet the criteria for continued inpatient mental health 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 the continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of an inpatient psychiatric hospital admission from August 12, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 7, 2020.
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 the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on October 29, 2020.
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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a history of hypertension and hyperlipidemia. She was evaluated for pain and did not report any opioid or other controlled substance medication use at the visit. The presumptive qualitative (screening) drug testing appears to have been negative. The criteria for definitive drug testing are not met and the testing was therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing rendered on October 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sucraid oral solution for the enrollee.
You asked the Plan to pre-approve Sucraid oral solution. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 pre-approve Sucraid oral solution for the enrollee.
Benefits for Sucraid oral solution 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography of the abdomen and pelvis; without contrast material (74176) provided on March 4, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 a diagnostic radiology service rendered by an in-network provider. 

You have been asked to pay a $100 copayment for the diagnostic radiology service provided. 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 the computed tomography of the abdomen and pelvis; without contrast material (74176) provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on August 13, 2020.

You asked the Plan to pay for moderate sedation services (99152). You say that the Plan should pay this claim. The Plan denied your request. The Plan says procedure code 00790 was billed on the same date of service by the same provider.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, we have confirmed that code 99152 has a bundled relationship with code 00790 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment (A9300) provided on February 10, 2021.
You asked the Plan to reimburse you for exercise equipment. You say that you were told on two occasions that exercise bikes were a covered benefit prior to your purchase. The Plan denied your request. The Plan says the
exercise equipment was purchased on February 10, 2021. Per the temporary Coronavirus policy, you could use your Wellness Allowance towards the purchase of equipment from October 1, 2020 - December 31, 2020; therefore, the Plan is unable to approve your request.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan can pay up to $250 per calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment that you can use at home. The Plan's rules for coverage of gym benefits have not been met because this purchase was made after the Plan's policy changes that began October 1, 2020 and ended December 31, 2020. Therefore, we decided that the Plan does not have to reimburse you for exercise equipment (A9300) provided on February 10, 2021.
Your complaint about receiving misleading information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. The record clearly indicates that you were given misleading information; therefore, you should continue to contact the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.

You asked the Plan to pre-approve the CGM supplies. You say that you are completely out of sensors and do not have another way to test your blood sugar. The Plan denied your request. The Plan says the information provided shows the enrollee has not been seen by her physician since 2019.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above.

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 CGM supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has diabetes with the latest A1C test results of 6.7 but takes no prescription medication. The documentation shows that the enrollee has been using a blood glucose monitor (BGM) and performing testing four or more times a day. The enrollee is not insulin treated with three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. The enrollee's insulin treatment regimen does not require frequent adjustment by the enrollee on the basis of BGM or CGM testing results. The documentation provided by the appellant does not demonstrate that Medicare coverage criteria have been met. 

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 CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120).
You asked the Plan to pre-approve the additional non-emergency transportation. The Plan denied your request. The Plan says you have used the 60 one-way trips of the 60 allowed by the Plan. The Plan also says that you currently have no trips remaining and the requested services will exceed the benefit limit.
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 up to 60 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 non-emergency transportation (A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 12, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that that due to a short time period you were unable to obtain an authorization. The Plan denied your request. The Plan says the provider is out-of-network
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 drug testing provided on February 12, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 2, 2021, by an 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 March 2, 2021, by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided March 4, 2021.
You asked the Plan to pay for the discharge day management services. You say that you believe that the services were medically necessary and the review of the submitted records will prove it. The Plan denied your request. The Plan says the records do not support the service 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. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management, 30 min.
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more. The records show that the Plan made multiple attempts to obtain the additional information without success. Based on this information, we decided that Medicare rules for coverage of the discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239) provided March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 9, 2020.
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 the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a panoramic radiographic image (D0330), an immediate upper denture (D5130), an immediate lower denture (D5140), and extractions (D7140 x8) provided on February 17, 2021.
You asked the Plan to pay for a limited oral evaluation, a panoramic radiographic image, an immediate upper denture, an immediate lower denture, and extractions. You say that you could not wait to see an in-network provider. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, a panoramic radiographic image, an immediate upper denture, an immediate lower denture, and extractions have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a limited oral evaluation (D0140), a panoramic radiographic image (D0330), an immediate upper denture (D5130), an immediate lower denture (D5140), and extractions (D7140 x8) provided on February 17, 2021.