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

We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care after March 26, 2020.
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the services are not covered.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. There is no documentation in the case file that shows the Plan made any attempts to request medical records for review. Furthermore, the Plan has not provided any documentation showing that the enrollee used 100 days in her SNF benefit period. Therefore, we decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care after March 26, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), abutment supported porcelain/ceramic crown (D6058), and custom fabricated abutment (D6057).
You asked the Plan to pre-approve the endosteal implant, abutment supported crown, and custom fabricated abutment. You say that tooth #4 is missing and has to be replaced with an implant, with no other option. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), abutment supported porcelain/ceramic crown (D6058), and custom fabricated abutment (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that your current tank is too difficult to move and you desire to travel. The Plan denied your request. The Plan says there is no documentation from your pulmonologist that shows you are unable to use the portable oxygen tanks provided to you.
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. Medicare covers home oxygen. The record shows that you have a stationary oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks serves the same purpose as a portable oxygen concentrator. The record does not show the portable tanks do not meet your in-home needs. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
You asked the Plan to pre-approve a CGM. You say that the enrollee wants to use a CGM. The Plan denied your request. The Plan says the enrollee is not checking blood glucose more than twice per day an utilizing insulin only twice per day.
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 record shows criteria is not met. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided on December 6, 2019.
You asked the Plan to waive the copayment for outpatient lab work. You say that these services were all part of your annual wellness visit. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient diagnostic tests/lab tests. You have been asked to pay $12.17 ($6.42 + $5.75 = $12.17) which is less than your copayment amount of $30 for outpatient lab work. Outpatient lab work falls within the outpatient diagnostic tests/lab tests 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 outpatient lab work provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SoClean brand CPAP cleaning machine.
You asked the Plan to pre-approve a SoClean brand CPAP cleaning machine. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a SoClean brand CPAP cleaning machine is not a covered item under Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare says that routine periodic services, such as cleaning an enrollee's equipment is not covered. Therefore, we decided that the Plan does not have to pre-approve a SoClean brand CPAP cleaning machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard.
You asked the Plan to pre-approve the occlusal guard. You say that you have bruxism, which causes damage to your gums and teeth. You also say that you really need this dental guard. The Plan denied your request. The Plan says this service is not covered under your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 2.
You asked the Plan to pre-approve the dental service. You say that you need a crown. You say that you have heart issues. You say that if you do not get a crown you could end up with additional medical issues that could be more costly. The Plan denied your request. The Plan says crowns are not a covered service.
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 crown for tooth # 2 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 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 rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the medical record reflects the dispensing order. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are recovering from surgery and need orthotics while walking. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for services provided on October 19, 2019.
You asked the Plan to pay for the air ambulance services. You say that the air ambulance service was medically necessary. The Plan denied your request. The Plan says that the enrollee could have been safely transported by ground ambulance.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 the air ambulance services. Our reviewer says that the service was medically necessary. Our physician reviewer found the documentation does support that the enrollee suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The enrollee had a posterior dislocation of an artificial hip joint which was unable to be reduced in the transferring hospital. The documentation does support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. Ground transport would have taken approximately 1 hour and 43 minutes. The documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. The transferring hospital attempted to reduce the dislocated hip and was unable to do so. The enrollee required transfer to a facility with higher level of orthopedic care than was available in the transferring facility. 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 air ambulance services have been met. Therefore, we decided that the Plan has to pay for services provided on October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam tablets.
You asked the Plan to pre-approve Lorazepam tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Lorazepam tablets are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lorazepam tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for morphometric analysis testing provided on October 31, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because these services have been misrepresented.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for morphometric analysis testing provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary bike.
You asked the Plan to pre-approve a stationary bike. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a stationary bike is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stationary bike.
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 the SNF services. You say that you are not stable to leave the facility at this time. The Plan denied your request. The Plan says the enrollee is no longer eligible for skilled nursing care during this benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from October 18, 2019 to April 13, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for the lower left quadrant.
You asked the Plan to pre-approve the dental service. You say that you never received any notice, letter, or call notifying you that the service would not be covered. You say that this has happened twice now. You also say that you scheduled transportation to go to your dental appointment and were advised upon arrival that it would not be covered. The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service.
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 scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for the lower left quadrant.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for chemotherapy administration (96401x3) provided on May 10, 2019.

You asked the Plan to pay for the chemotherapy administration. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the record only supports two units of this service.

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 96401x3 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.

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 the chemotherapy administration. Our reviewer says that the administration of 3 units of CPT Code 96401 (chemotherapy administration, subcutaneous or intramuscular; nonhormonal antineoplastic) is supported by the medical record. Our physician reviewer found the case file contains documentation of Nucala (Mepolizumab) administration, 300 mg, 3 vials.

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 chemotherapy administration have been met. Therefore, we decided that the Plan has to pay for chemotherapy administration (96401x3) provided on May 10, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services to be provided by an out of network (OON) provider, 
You asked the Plan to pre-approve the mental health services. You say that the services are medically necessary. The Plan denied your request. The Plan says 2 visits have been approved to allow transition to a new provider. Ongoing visits are denied as there are network providers who can provide the services at issue.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Please note the record shows the plan has already approved 2 visits to allow transition to a new provider. We decided that the Plan does not have to pre-approve additional visits
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 the SNF services. You say that you would benefit from short-term rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF coverage because he does not have any skilled care needs.
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 necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, had wound vac changed 3 times per week, and had routine foley catheter care. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was dependent for mobility and 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 meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the record shows the enrollee can reduce pressure and does not have a condition meeting criteria.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows that the enrollee's condition can be improved by a walker or cane and the enrollee will use a walker in the home and the power wheelchair outside in the community. Medicare does not cover power wheelchairs for use only outside the home. The enrollee's diagnoses do not meet criteria. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.