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

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with multiple power options.

You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested Group 3 power wheelchair is not medically necessary because a power seating system is not 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 a Group 3 power wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has had a diagnosis for multiple sclerosis. Co-morbidities include left eye lost vision, gait imbalance, and fatigue. The enrollee has a personal mobility deficit that impairs participation in MRADLs and is unable to be helped by a walker, cane, or manual wheelchair due to upper extremity weakness. The enrollee is noted to be able to safely operate a PMD and has a covered indication of multiple sclerosis for a Group 3 power wheelchair. However, the enrollee does not have a high risk for development of a pressure ulcer, utilize intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The requested Group 3 power wheelchair and accessories is not medically necessary as it exceeds the enrollee's medical needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with multiple power options
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) rendered by the out of network (OON) provider.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The record indicates that the transfer of the enrollee to this hospital was non-emergent. As such, the hospital had an obligation to request authorization for these services prior to the enrollee being transferred. 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 critical care, evaluation and management of the critically ill (99291) rendered by the out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient services provided by an out-of-network provider.

You asked the Plan to pay for inpatient services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says that prior authorization was not obtained.

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. the Plan has failed to send in a 2020 EOC. The proper 2020 EOC is required in order to render a decision. Therefore, we decided that the Plan has to pay for inpatient services provided by an out-of-network provider.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden for diagnosis liver cell carcinoma (CPT code 0037U) provided to the enrollee.

You asked the Plan to pay for the laboratory services. You say that the service is necessary. The Plan denied your request. The Plan says they did not find any records to prove extenuating circumstances that would justify this extensive gene test. The Plan states they did not find any literature (peer-reviewed) that states this test is medically necessary for the condition of liver cell carcinoma and most of the testing is still under research at this time.

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 pay for the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested item. The review has determined that the items/services at issue in this case are not medically reasonable or 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 the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden for diagnosis liver cell carcinoma (CPT code 0037U) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee scooter (E0118).

You asked the Plan to pay for a knee scooter. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The DME MAC has determined that there is not sufficient evidence to support the medical necessity of a knee scooter at this time. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pay for a knee scooter (E0118).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CGP testing (CPT code (s): 81479-59, 81302-59, 81408-59, 81330-59, 81345-59 and 81407-59) provided to the enrollee.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. As CGP testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code. To report a CGP service, providers should use CPT code 81479 once as a bundled code for the entire bundled multi-test panel at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. If CPT 81479 also is on the claim as coding for an unlisted service (not as the bundled services), in that use the unlisted code CPT 81479 is included in the bundle and must meet the unlisted code requirement of a detailed narrative explanation on the claim or attached to the claim. Coverage of CGP is limited to one bundled test per specimen and precludes the use of any other molecular testing on the specimen. Therefore, we decided that the Plan does not have to pay for CGP testing (CPT code (s): 81479-59, 81302-59, 81408-59, 81330-59, 81345-59 and 81407-59).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically reasonable and necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the prescribing physician and the enrollee.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the obtained laboratory studies.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no authorization for this service.

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 physician's 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 physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis (L1971), suspension sleeve (L2397), and miscellaneous supply (A9900).

You asked the Plan to pay for the ankle foot orthosis, suspension sleeve, and miscellaneous supply. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the billed supply code cannot be verified.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery and an itemized shipping/billing invoice to indicate the specific supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1971), suspension sleeve (L2397), and miscellaneous supply (A9900).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Toric Lenses (V2787).

You asked the Plan to pay for the Toric Lenses. You say that you would like reconsideration because these lenses were the best option for you and would be better for your eyes. The Plan denied your request. The Plan says the astigmatism correcting function of intraocular lens are Non-covered by Medicare statute.

The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL.

While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the Toric Lenses (V2787).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth implant and bone grafting.

You asked the Plan to pay for the tooth implant and grafting services. You say that you switched over to this Plan because you were told that more services, including the tooth implant and bone grafting, would be covered. The Plan denied your request. The Plan says tooth implanting and related services are not covered by Medicare or by the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the tooth implant and bone grafting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) rendered by the out of network (OON) provider.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The record indicates that the transfer of the enrollee to this hospital was non-emergent. As such, the hospital had an obligation to request authorization for this service prior to the enrollee being transferred. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care, per day (99233) rendered by the out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 20, 2019.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for this service was not filed until October 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for residential treatment services provided to the enrollee from July 8, 2020, through July 9, 2020, by a non-Medicare provider.

You asked the Plan to pay for the services. You say that the provider is a community-based treatment facility for both mental health and substance abuse disorder. The Plan denied your request. The Plan says it was determined that in order for a provider to receive payment for a Medicare member, the provider must be certified (approved to participate) in the Medicare program.


The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The provider does not have a Medicare number or a CMS Certification. The rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for residential treatment services provided to the enrollee from July 8, 2020, through July 9, 2020, by a non-Medicare provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 19, 2020, to November 25, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not owe a copayment due to the quality of care you received. 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 $180 copayment, for days 1-7 for inpatient hospital care. 

You had an inpatient hospital stay from November 19, 2020, to November 25, 2020. Therefore, you are responsible to pay a $180 copayment for days 1-6 (November 19, 2020, to November 24, 2020). $180 (copayment) x 6 (inpatient days) = $1,080. 

You have been asked to pay the total copayment amount of $1,080 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 19, 2020, to November 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says LTACHs do not provide clinical advantage over a non LTACH acute care hospitals.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COViD-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient is currently undergoing treatment at an acute care hospital (ACH) for pneumonia, in the setting of pulmonary fibrosis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.