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

We decided that the Plan does not have to pay for the Domiciliary or rest home visit for the evaluation and management of an established patient (99334) provided on September 16, 2020, by an out of network (OON) provider. You asked the Plan to pay for the physician visit. You say that the hospital staff should have obtained prior authorization and the provider should not be held liable for the costs. The Plan denied your request. The Plan says prior authorization was not obtained and OON criteria were not met for the services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the Domiciliary or rest home visit for the evaluation and management of an established patient (99334) provided on September 16, 2020, by an out of network (OON) provider.
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 enrollee meets the criteria for LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 there are no services available at the LTACH that the enrollee requires that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically reasonable, necessary, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this 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 the RFA. Our reviewer says that the requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer found that RFA of the lateral sacral roots is considered experimental/investigational because of the wide variation in efficacy in published reports. Therefore, the request is considered 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the criteria has been met.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee is not maintained on insulin therapy. The documentation indicates that the enrollee has not been using insulin multiple times (3 or more) a day. The treatment does not require frequent adjustment on the basis of testing results. 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 pre-approve a Freestyle Libre 14 day sensor for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the implantation of neurostimulator (63650).

You asked the Plan to pre-approve the implantation of neurostimulator. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that coverage criteria is not met and this service is therefore not medically necessary and reasonable.

The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered when the Medicare criteria as listed in the Rules section is met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the implantation of neurostimulator. Our reviewer says that the requested service is medically necessary and reasonable according to the Medicare criteria listed in the Rules section. Our physician reviewer found in this case the member is noted to have low back pain. She is said to have had an inadequate response to multiple therapies to date. She has been determined not to be a surgical candidate by a neurosurgeon. The spinal cord stimulator would be a therapy of "last resort". She has received psychological clearance for spinal cord stimulator placement. In this setting it appears that the requirements of the NCD and LCD for a trial of a SCS placement would be satisfied 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 the implantation of neurostimulator have been met. Therefore, we decided that the Plan has to pre-approve the implantation of neurostimulator (63650).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says IRF care 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does 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. Finally, there is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis.

You asked the Plan to pay for the wrist hand orthosis (L3916RT). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says there are no claims from the ordering physician and no medical records showing the prescribing physician ever saw 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 pay for the wrist hand orthosis (L3916). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrists would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists.

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 wrist hand orthosis (L3916RT) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME.
You asked the Plan to waive the coinsurance for the DME. You say that you were told by the Plan not to pay the bill because the provider is not allowed to charge more than the agreed upon prices. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of $117.82 ($111.12 = 20% of $555.60) + $6.70 for uncovered costs) for the DME. This equipment falls within the durable medical equipment 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 coinsurance for the DME.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablations.
You asked the Plan to pre-approve radiofrequency ablations. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because research has not proven any method of ablation for sacroiliac joint pain to be helpful.
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 radiofrequency ablations. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation in efficacy in the reported literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablations.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on August 27, 2020.
You asked the Plan to pay for the topical application of fluoride varnish. You say that you were not advised that this service was not covered until after you received the treatment. The Plan denied your request. The Plan says 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 topical application of fluoride varnish (D1206) provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the criteria has been met. 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found insulin treatment is required for coverage of this monitor. You do not take insulin and therefore do not meet the criteria. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on June 22, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with records to substantiate the necessity of the services rendered. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels except the basic lipid panel.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Although the Plan stated that this testing is excluded from coverage, this testing is not excluded from Medicare Part B coverage in the geographic location of the laboratory. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on June 22, 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: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided on July 5, 2020, through August 3, 2020.
You asked the Plan to pay for the home health services. You say that you would like reconsideration because these services were billed correctly. The Plan denied your request. The Plan says that this claim lacks information or has billing errors.
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, the Plan has not failed sufficient information to substantiate their denial. The Plan has not indicated what information is missing or incorrect on the submitted claim. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor Therefore, we decided that the Plan has to pay for home health services provided on July 5, 2020, through August 3, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional component (L5631) for a preparatory prosthesis (L5590).
You asked the Plan to pre-approve the additional component. You say that this is medically necessary. The Plan denied your request. The Plan says the requested component is not reasonable and necessary for a preparatory prosthesis.
The Plan must follow Medicare rules. Medicare rules say that L5631 cannot covered in addition to an above knee preparatory prosthesis. The plan has approved an above knee preparatory prosthesis coded with L5590. The rules state that the requested component that is still at issue in this case (L5631) cannot be covered in additional to the main prosthesis. Based on this information, we decided that Medicare rules for coverage of the additional component have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional component (L5631) for a preparatory prosthesis (L5590).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS system for the enrollee. You asked the Plan to pre-approve the CardioMEMS system. You say that this is medically necessary. The Plan denied your request. The Plan says that that the clinical value and effectiveness of the CardioMEMs device in the setting of Congestive Heart Failure has not been demonstrated in the peer reviewed literature. 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 CardioMEMS system. Our reviewer says that the CardioMEMS system is considered medically reasonable and necessary in this case. The Cardiomems device is being prescribed for an enrollee with the approved indication. Literature is available that supports its efficacy in this population. The CardioMEMS system is part of the standard of care to be used as the physician deems appropriate in the appropriate clinical setting. Our physician reviewer found that the enrollee's condition meets criteria for coverage of the CardioMEMS system. 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 CardioMEMS system have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS system 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97112, 97530) provided on November 11, 2020, through November 18, 2020.
You asked the Plan to waive the copayment for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says your claims were processed correctly according to your Plan benefit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for outpatient rehabilitation services. The enrollee has been asked to pay a $25 copayment for the physical therapy services. Physical therapy falls within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy services (97112, 97530) provided on November 11, 2020, through November 18, 2020.