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

We decided that the Plan does not have to pre-approve a PureWick female external catheter system (K1006).

You asked the Plan to pre-approve a PureWick system. You say that the requested care is a necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a Medicare benefit.

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 PureWick system. 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 was recently discharged from the hospital after treatment of pleural effusion and congestive heart failure. Medical records indicate that the enrollee has chronic renal disease and a midline cystocele. The records provided do not mention urinary incontinence. There are no peer-reviewed articles published in the medical literature specific to the PureWick system, or external urinary collection system using a continuous low-pressure pump. Thus, there is no evidence to show the PureWick system to be an equally effective method for managing urinary incontinence. 

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 PureWick system have not been met. Therefore, we decided that the Plan does not have to pre-approve a PureWick female external catheter system (K1006).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PureWick urine collection system (K1006).
You asked the Plan to pre-approve the PureWick urine collection system. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PureWick urine collection system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the PureWick urine collection system is considered unproven and not medically necessary for the management of urinary incontinence. 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 PureWick urine collection system have not been met. Therefore, we decided that the Plan does not have to pre-approve the PureWick urine collection system (K1006).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metaxalone.
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 self-administered drugs are not covered.
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 Metaxalone.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided from December 22, 2020, through December 25, 2020.
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says the services were performed without authorization from the Plan.
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 subsequent hospital care provided from December 22, 2020, through December 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from August 8, 2020, through August 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services were rendered without 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. 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 physician's services provided from August 8, 2020, through August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the intravenous infusion services (96365, 96375) provided from December 3, 2020, through December 17, 2020.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $250.00 copayment per visit for in-network Medicare-covered ambulatory surgical center and outpatient hospital facility visits. 

You have been asked to pay $750 ($250 copayment x 3 visits) for the outpatient hospital services 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 copayments for the intravenous infusion services (96365, 96375) provided from December 3, 2020, through December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hyperbaric medicine office visit provided on May 22, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you do not understand why you owe this amount and have a limited income. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $45 copayment for in-network specialist visit. You have been asked to pay $45 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office 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 waive the copayment for a hyperbaric medicine office visit provided on May 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 10, 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 procedure codes 95939, 95927, A4215, 95938, 95861 and 95868 are not supported.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21. We looked at the file and Medicare rules. The file shows that the services were billed with POS code 15 for a mobile unit while the enrollee was under inpatient status. These services must be billed with POS code 21 for inpatient hospital. Therefore, we decided that the Plan does not have to pay for the testing services rendered on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on February 15, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that your most recent full mouth set of x-rays was provided on October 17, 2017, which is more than 36 months ago. The Plan denied your request. The Plan says this benefit has been exhausted.
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 once every 36 months. The record shows that you received a complete series of intraoral x-rays on February 15, 2021, and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery and coinsurance for an injection provided by a participating provider on December 11, 2020.
You asked the Plan to waive the deductible for an outpatient surgery and coinsurance for an injection. You say that you should not be charged more than a $35 copayment for this. The Plan denied your request. The Plan says the correct deductible and coinsurance 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 $750 deductible and a 20% coinsurance for Medicare Part B drugs/in-network and outpatient surgery. You have been asked to pay a $61.75 for an outpatient surgery and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $5.32. The total amount for an injection is $1.06 ($5.32 x 20% = $1.06). The total amount you are being asked to pay is $62.81 ($61.75 + $1.06 = $62.81). An injection falls within the Medicare Part B drugs/in-network benefit category and an outpatient surgery falls within the 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 deductible for an outpatient surgery and coinsurance for an injection provided by a participating provider on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on October 12, 2020.
You asked the Plan to pay for the endodontic therapy. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you contacted the Plan on July 8, 2020 and were advised that this service is 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 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 endodontic therapy provided on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on November 18, 2020.
You asked the Plan to pay for the re-treatment of previous root canal therapy. You say that you believe these services should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the consultation (D9310) provided on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 18, 2020 by an out of network (OON) provider.
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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 the laboratory services provided on December 18, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON oncology services. You say that it is felt that OON care is required because the surgery needs to be done sooner than later to ensure it does not spread. The Plan denied your request. The Plan says the enrollee has a timely consultation with an in-network surgeon. There is no evidence that the surgery cannot be done within a reasonable time frame.
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. Therefore, we decided that the Plan does not have to pre-approve surgical oncology services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for shortness of breath and lower extremity swelling and weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1 additional skilled nursing home health visit and 95 additional home health aide hours.
You asked the Plan to pre-approve 1 additional skilled nursing home health visit and 95 additional home health aide hours. You say that these services are medically necessary. The Plan denied your request. The Plan says these requested services beyond what have already been approved are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. The rules also say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 1 additional skilled nursing home health visit and 95 additional home health aide hours. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services beyond those already approved by the health plan are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. In addition, there is no documentation that the home health aide services beyond those already approved by the health plan are reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 additional skilled nursing home health visit and 95 additional home health aide hours have not been met. Therefore, we decided that the Plan does not have to pre-approve 1 additional skilled nursing home health visit and 95 additional home health aide hours.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the insertion of catheters for recording, pacing, and destruction of tissue to treat abnormal heart rhythm (93656).
You asked the Plan to pre-approve cardiac ablation services. You say that this request is medically necessary. The Plan denied your request. The Plan says that the requested services are not medically necessary and reasonable.
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 cardiac ablation services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 66-year-old woman with end stage renal disease on chronic hemodialysis. The patient has recurrent symptomatic paroxysmal atrial fibrillation (AF) although this has improved on therapy with metoprolol. She is tolerating appropriate anticoagulation therapy. She has not been treated with any rhythm control agents as initial management for her paroxysmal AF. Current Health Resources and Services Administration guidelines generally recommend an attempt at rhythm control with at least one agent before consideration of radiofrequency ablative therapy (1) although consideration of AF ablation without prior medical therapy is considered reasonable as a Class IIa indication based on specific patient criteria and preferences (1). Also in this situation, her end stage renal failure may limit the use of certain rhythm control agents and complicate medical management, and her physician is contending that the atrial flutter component of her arrhythmia would make medical management possibly less effective We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cardiac ablation services have been met. Therefore, we decided that the Plan has to pre-approve the insertion of catheters for recording, pacing, and destruction of tissue to treat abnormal heart rhythm (93656).
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.