Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital 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. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
respiratory infections. The enrollee is not intubated/ventilated. 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 (LTC) 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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage (A0425) provided July 10, 2019.
You asked the Plan to pay for the ambulance service. You say that this was an emergency transportation and the records should support the necessity of the services.] The Plan denied your request. The Plan says the presence of the modifier GY indicates this claim is not eligible for payment.
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, this claim was billed with the GY modifier indicating that this claim is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage (A0425) provided July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visits provided on February 14, 2019, April 4, 2019 and June 18, 2019.
You asked the Plan to pay for the domiciliary or rest home visits. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 domiciliary or rest home visits provided on February 14, 2019, April 4, 2019 and June 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 26, 2019 to August 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were not billedcorrectly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is required for home health claims.We looked at the file and Medicare rules. The file shows that the claims were not billed with the required treatment authorization code. 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 forthe home health services rendered from August 26, 2019 to August 30, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Single-Photon Emission Computed Tomography
(SPECT) test.
You asked the Plan to pre-approve SPECT test. You say that you are appealing based on medical necessity.
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this
SPECT test 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 SPECT test. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has some coronary risk, atypical chest pain, normal electrocardiogram (EKG) and a
prior normal stress test. If additional evaluation were thought to be medically necessary, then routine treadmill
electrocardiography would be sufficient. The enrollee does not have known coronary artery disease,
documented inability to ambulate on a treadmill or an abnormal baseline electrocardiogram that reduces
interpretation accuracy during exercise stress.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SPECT test have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Single-Photon Emission Computed Tomography (SPECT) test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on September 5, 2019.You asked the Plan to pay for the complete series of intraoral x-rays. You say that the Plan will not pay your dental bill.The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.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, full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a complete series of intraoral x-rays on August 20, 2019 and your full mouth or panoramic x-rays benefit is now exhausted.Therefore, we decided that the Plan does not haveto pay forthe complete series of intraoral x-rays provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and upgraded electronics from NuMotion.
You asked the Plan to pre-approve a power seat elevation system and upgraded electronics. You say that the enrollee needs a power seat elevation system and upgraded electronics. The Plan denied your request. The Plan says power seat elevation systems are not covered by Medicare and the upgraded electronics are not medically necessary.
The Plan follows Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.
Documentation shows that the enrollee has normal range of motion and 3/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Power seat elevation systems are not covered by Medicare or the Plan. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and upgraded electronics (E2313, E2377, E2311) from NuMotion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960), an ankle-foot orthosis (L1971), a lumbar-sacral orthosis (L0650), a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 26, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960), an ankle-foot orthosis (L1971), a lumbar-sacral orthosis (L0650), a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you don't believe you are responsible for the services. You say that it was a one way trip because you were admitted and you could not drive yourself.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does notpay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 17, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on March 29, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on March 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe BLS non-emergency ambulance services provided on August 3, 2019 by out of network provider, "the provider". You asked the Plan to pay forthe ambulance services. You say that reimbursement of this claim in the amount of $0 is not acceptable. The enrollee had active coverage and this was a medically necessary transport.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. Prior authorization is required for non-emergency ambulance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue.We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe BLS non-emergency ambulance services provided on August 3, 2019 by out of network provider, "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe limited oral evaluation, bitewing x-rays, intraoral periapical x-rays, inhalation of nitrous oxide, and the surgical extraction provided from July 9, 2019 to July 11, 2019.You asked the Plan to reimburse you forthe dental services. You say that you were not advised that the provider was out of network. You say that the extraction was emergent.The Plan denied your request. The Plan says the provider in this case is not a network provider with the Plan. The Plan also says that services received out of network are not covered.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 thePlan offers a dental benefit in excess of Medicare coverage and the services could be covered, the services are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to reimburse you forthe limited oral evaluation, bitewing x-rays, intraoral periapical x-rays, inhalation of nitrous oxide, and the surgical extraction provided from July 9, 2019 to July 11, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe.You asked the Plan to pre-approve Prolia 60 mg/ml syringe. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia 60 mg/ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Prolia 60 mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60 mg/ml syringe
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
You asked the Plan to pre-approve the compression stockings. You say that your healthcare provider ordered a type of sock that squeezes your legs, called gradient compression stockings, to help with blood flow in your legs. The Plan denied your request. The Plan says gradient compression stockings A6531 are non-covered when there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided from March 15, 2019 to June 27, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. ThePlan did not pre-approve the service 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 physician services provided from March 15, 2019 to June 27, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent urinary catheter (A4353).
You asked the Plan to pay for intermittent urinary catheter. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
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 shows that the Plan made several attempts to obtain the itemized shipping/billing invoice for the items at issue in this appeal. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies. Therefore, we decided that the Plan does not have to pay for intermittent urinary catheter (A4353).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for outpatient mental health services.You asked the Plan to adjust the copayment for the services. You say that your copayment was $20 last year.The Plan denied your request. The Plan saysthe copayment for these services is $40 this year.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 $40 copayment for individual or group therapy visits. You have been asked to pay a $40 copayment for the services. The services fall within the individual or group therapy visits 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 adjust the copayment for outpatient mental health services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary for treatment of Hodgkin's lymphoma.
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 therapy. Our reviewer says that the requested therapy is considered medically reasonable and necessary in this case. Our physician reviewer found while the justification for IMRT (vs 3D) is relatively weak in this case, IMRT is an accepted standard based upon NCCN guidelines and ILROG consensus guidelines, albeit with the justification primarily based upon the benefit for patients with thoracic treatment fields. The LCD criteria are met in that IMRT would be furnished in accordance with accepted standards of medical practice. 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 therapy have been met. Therefore, we decided that the Plan has to pre-approve intensity modulated radiation therapy 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 23, 2020.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are 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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on December 13, 2019. You received oral medications and had stable vital signs. You need minimal assistance with functional mobility, including walking 80 feet with a rolling walker. You need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond January 23, 2020.