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

We decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that the worst pain generator is the lower back pain which radiates to the bilateral buttocks, hips, and lower extremities. The Plan denied your request. The Plan says a prior injection should provide adequate pain relief for a period of three months.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee did not achieve sustained significant pain relief (3 months) from prior epidural steroid injections. The injection only provided only two weeks of pain relief. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a transforaminal epidural steroid injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, guided tissue regeneration, extraction, and bone replacement graft for ridge preservation provided by an opt out provider.

You asked the Plan to pay for the problem focused limited oral evaluation, guided tissue regeneration, extraction, and bone replacement graft. You say that you believe these services should be covered. The Plan denied your request. The Plan says services performed by a privately contracted provider are not paid for. The Plan also says that this provider opted out of Medicare.

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 problem focused limited oral evaluation, guided tissue regeneration, extraction, and bone replacement graft for ridge preservation provided by an opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you do not meet Medicare criteria for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) controller input device upgrades (E2377, E2313, E2311).

You asked the Plan to pre-approve the control input device upgrades. You say that the enrollee needs a Group 3 power wheelchair with power recline in addition to power tilt. The Plan denied your request. The Plan says they agreed to overturn the initial decision and found the Group 3 PWC was necessary, but the expandable controller upgrades were not.

The Plan must follow Medicare rules. The rules say that the approved power options come with their own switches.

The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The enrollee's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) controller input device upgrades (E2377, E2313, E2311).
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 to have hospital care while getting your rehab. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for upper gastrointestinal bleeding. Your medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 29, 2020 to August 30, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you strongly believe this admission was appropriate, and expect full reimbursement as the services rendered could not have been provided in an outpatient setting. The Plan denied your request. The Plan says that based on the medical documentation, observation level of care was appropriate for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found in this case, the enrollee had underlying co-morbidities which placed him at high risk for decompensation. In addition, he presented with acute onset of abdominal pain, a soft blood pressure, acute kidney injury, an increased hernia size, elevated white blood cell count and elevated lactate. There was a reasonable expectation that the hospital stay would scan two midnights and that inpatient services were required. Therefore the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 29, 2020 to August 30, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Leuprolide Acetate injection (J9217) provided on July 30, 2020.
You asked the Plan to waive the coinsurance for the drug services. You say that the Plan did not cover this drug, although they had covered it previously. The Plan denied your request. The Plan says this drug is covered but requires 20% coinsurance.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the drug services. The Plan's approved amount for this service is $1,525.19 and you were asked to pay $305.04 ($1,525.19 x 20% = $305.04). A Leuprolide Acetate injection falls within the Medicare Part B prescription drugs 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 Leuprolide Acetate injection (J9217) provided on July 30, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that the requested proton beam therapy is medically necessary. The Plan denied your request. The Plan says that the requested proton beam therapy is not medically necessary.
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 proton beam therapy. Our reviewer says that the requested proton beam therapy is medically necessary. Our physician reviewer found for prostate cancer, the LCD (L30575) require physician documentation of the patient "stage and other factors" (which would include Gleason score and PSA) and documentation of the range of therapy choices which is documented in the consultation note. As the LCD criteria have been met, the requested proton beam therapy should be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites provided on September 23, 2020.
You asked the Plan to pay for the resin-based composites. You say that you were told that you have a $2,500 allowance to use toward dental services. The Plan denied your request. The Plan says your benefits for this service had been satisfied and the frequency limitation had 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, restorations (fillings) are limited to two procedures per calendar year. The record shows that you received four resin-based composites on September 23, 2020, two of which were covered by the Plan, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the two resin-based composites provided on September 23, 2020.
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 you would like reconsideration because the LTACH admission provides the best chance for vent weaning. The Plan denied your request. The Plan says there is no clinical advantage of an LTACH over an acute hospital.

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 does not require services at the LTACH that are not available at the acute care hospital where she/he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1844).
You asked the Plan to pre-approve the orthosis. You say that the orthosis is medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that an orthosis is covered if the beneficiary has had a
recent injury or a surgical procedure.
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 orthosis. Our reviewer says that the
orthosis is not medically necessary. Our physician reviewer found the enrollee has not had a recent injury or
surgery to the left knee. While the enrollee is ambulatory, there is no evidence of left knee instability on a
physical examination.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a knee orthosis (L1844).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385).

You asked the Plan to waive the copayment for the colonoscopy services. You say that you did not have a copayment for this service in the past. You also say that you do not feel it is fair that this service is considered diagnostic because you have not experienced symptoms related to your condition in many years. The Plan denied your request. The Plan says the colonoscopy was diagnostic and therefore the outpatient surgery cost-share applies.

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 $300 copayment for outpatient surgery services, and this copayment will apply with non-diagnostic or routine colonoscopies.

You have been asked to pay a $300 copayment for the colonoscopy services. Medical records were provided in this case that show that you have a history of ulcerative colitis. Therefore, this procedure is considered diagnostic rather than a screening and the outpatient surgery cost-share applies. 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 the colonoscopy with lesion removal (45385).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for waterproof tape (A4452), gauze (A6219), and conforming bandage (A6446).
You asked the Plan to pay for waterproof tape, gauze, and conforming bandage. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the record does not include a valid physician order.
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 physician order. In this case, the physician order does not include the physician's signature. 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 waterproof tape (A4452), gauze (A6219), and conforming bandage (A6446).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 14, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there are no medical records or clinical documentation for review.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on August 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to waive the copayment for outpatient mental health care provided on September 18, 2020, and October 23, 2020.
You asked the Plan to waive the copayment for outpatient mental health care. You say that you were sent a card stating that outpatient behavioral health visits would not have a copayment. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for outpatient mental health care when provided at rural health clinics. The record shows that you received outpatient mental health services from September 18, 2020, to October 23, 2020, for a total of 3 visits. The provider is identified as a rural health clinic. Your contract with the Plan does not clearly state how much you should expect to pay for outpatient mental health services provided at a rural health clinic. Therefore, you cannot be asked to pay the total copayment amount of $120. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $40 copayment for outpatient mental health care when provided in a rural health clinic. The Plan contract does not clearly say how much enrollees must pay for outpatient mental health care when provided at a rural health clinic. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for outpatient mental health care provided on September 18, 2020, and October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided September 10, 2020, through September 18, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were told by the provider that there would be no copayment for the services. The Plan denied your request. The Plan says the copayment was applied correctly.
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 $300 copayment per day for days 1-5 per hospital stay. The enrollee has been asked to pay a total of $1,500 ($300 copayment x 5 days) for the inpatient rehabilitation services. These services fall within the Inpatient hospital care 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 the inpatient rehabilitation services provided September 10, 2020, through September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance.

You asked the Plan to pay for the periodontal maintenance. You say that this service is done for health protection and should be covered. 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 periodontal maintenance.