Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hearing aid cleaning (99213).

You asked the Plan to pre-approve the hearing aid cleaning. You say that the hearing aid services were covered in the past and should be covered again.The Plan denied your request. The Plan says this service is only covered for the first year after the hearing aid is provided.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aid adjustments only for 1 year after they are provided.

We looked at the file and the Plan's rules. The hearing aid was provided more than a year ago. Based on this information, we decided that the Plan's rules for coverage of the hearing aid cleaning have not been met.Therefore, we decided that the Plan does not have to pre-approve a hearing aid cleaning (99213)
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 cannot be adequately cared for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee was admitted to the current acute care hospital with acute on chronic COPD exacerbation and possible urinary tract infection. He was treated with antibiotics and oxygen. He aspirated upon swallow evaluation. A CT scan of the chest showed hypopharyngeal mass, diagnosed as squamous cell carcinoma. He required tracheostomy and PEG tube placement as well as ventilator support. He is being treated with wound care and diuresis for congestive heart failure. Recent notes state he is tolerating trach collar and off vasopressors. The enrollee appears to be more stable, but guarded. He does require additional short term acute care services, which can be safely administered at the current facility. He does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy session (97161) provided on October 22, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you cannot afford the copayment for physical therapy. The Plan denied your request. The Plan says physical therapy has a $40 copayment.
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 outpatient rehabilitation services. You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation services 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 the physical therapy session (97161) provided on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the spine billed using CPT code 72114 for date of service July 9, 2020. You asked the Plan to pay for CPT code 72114. You say that the records provided support the code in dispute. You say that there are not any CCI conflicts for the CPT code combinations billed, and a modifier is not required to identify these services as separate and distinct procedures. The Plan denied your request. The Plan says the physician performed a procedure described by CPT codes that describe a radiologic examination of the entire spine at the same patient encounter, where a CPT code which describes a radiologic examination of specific regions of the spine was billed. The Plan says that the physician should have summed the total number of views and reported the appropriate code in the CPT code range of 72081-72084. The physician should not also report another code in the CPT code range of 72020-72120 for services performed at the same patient encounter. 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, the CPT Code Manual definition of code 72114 is radiologic examination, spine, lumbosacral; complete, including bending views, minimum of six views. We find that CPT code 72114 is not supported in the medical record. Specifically, the enrollee underwent frontal, lateral, oblique, and flexion-extension views of the lumbar spine, and frontal and lateral views of the entire spine. The enrollee underwent two sets of imaging on July 9, 2020, both of which included frontal and lateral views of the lumbar spine. The sum the total number of views should have been submitted, and reported with the appropriate code in the CPT code range. Based on this information, we decided that Medicare rules for coverage of CPT code 72114 have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the spine billed using CPT code 72114 for date of service July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and 2D oral/facial photographic image (D0350) provided on October 5, 2020, and October 13, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation and 2D oral/facial photographic image. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says these services are not covered benefits 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 comprehensive periodontal evaluation (D0180) and 2D oral/facial photographic image (D0350) provided on October 5, 2020, and October 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefinancial compensation for caregiver services.You asked the Plan to pre-approvethe financial compensation for caregiver services. You say that you would like reconsideration because you have trouble walking and breathing.The Plan denied your request. The Plan says this service is not eligible for coverage by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the financial compensation for caregiver services have not been met. Specifically, there is no indication that the member's physician has ordered home health care. Additionally, custodial care is not a covered benefit.Therefore, we decided that the Plan does not have to pre-approvefinancial compensation for caregiver services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided from August 23, 2020, to August 24, 2020.You asked the Plan to pay forSNF services provided from August 23, 2020, to August 24, 2020. You say that the services which the enrollee required and received on the dates of service in this case are coverable under the Medicare Act.The Plan denied your request. The Plan says that by August 23, 2020 the enrollee's care could safely be provided at a custodial level of care by the extended care facility custodial level of care as it had been prior to the SNF admission.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 pay for SNF services provided from August 23, 2020, to August 24, 2020.. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services provided from August 23, 2020, to August 24, 2020. have not been met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided from August 23, 2020, to August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7953) for the enrollee.

You asked the Plan to pre-approve the services. You say that this should be covered.The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve dental services (D7953) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your doctor prescribed orthotics for you. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of Tremfyainjections, 100 mg/ml.You asked the Plan to pre-approvethe continuation of Tremfya injections. You say that the enrollee has been on Tremfya for over a year with great improvement and clearance. You also say that this is a request for continuation of treatment.The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is notcovered under Medicare Part B.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-approvethe continuation of Tremfya injections, 100 mg/ml.Benefits for the continuation of Tremfya injectionsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventive service (D1999), the core build up (D2950 x 2), the additional periapical x-ray (D0230), and the crowns (D2740 x 2) provided from August 17, 2020, to August 31, 2020.You asked the Plan to pay forthe dental services. You say that you are on a very limited income. You say that you cannot afford to pay for these services. You say that you need partial dentures so that you can eat. You also say that you cannot get those because you have an outstanding balance.The Plan denied your request. The Plan says the unspecified preventive service is not listed as a covered service. The Plan says that core build up is not listed as a covered service. The Plansays 1 periapical x-ray is covered per calendar year. The Plan says 2 crowns are covered per calendar year. The Plan also says that the frequency limits for these services have 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, the unspecified preventive service and core build up are not among those covered under this benefit. Additionally, the frequency limits for the periapical x-ray and crowns have been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on August 17, 2020 and 2 crowns that you received on August 31, 2020.Therefore, we decided that the Plan does not have to pay forthe unspecified preventive service (D1999), the core build up (D2950 x 2), the additional periapical x-ray (D0230), and the crowns (D2740 x 2) provided from August 17, 2020, to August 31, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating provider on August 3, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that your provider did not tell you that you would owe a $150 copayment. The Plan denied your request. The Plan says the correct copayment 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 $150 copayment for outpatient hospital services. You have been asked to pay a $150 copayment for outpatient hospital services. Radiology services billed by the hospital will incur a copay; therefore, the correct copayment has been applied. Outpatient hospital services falls within the outpatient hospital services 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 outpatient hospital services provided by a participating hospital on August 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePSG; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (CPT Code 95810).

You asked the Plan to pre-approvethe PSG. You say that the service is necessary.The Plan denied your request. The Plan says to have this request approved your healthcare provider should submit records showing that you have one of the following conditions: severe lung or heart disease, neurological issues that cause lung disease such as post-polio syndrome, obesity hypoventilation syndrome, pulmonary hypertension, unstable irregular heartbeats, a home sleep study could not establish difficulty breathing while sleeping, or you are unable to operate home sleep study equipment. The Plan states the medical information they received show that you do not have any of the above listed conditions.

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 PSG. Our physician reviewer found coverage criteria for attended diagnostic PSG are not met. You have known obstructive sleep apnea (OSA), and the records do not indicate why a repeat diagnostic PSG is necessary. As of December 11, 2020, you were unable to use continuous positive airway pressure (CPAP) because of pain related to cochlear implants.  The records do not show whether that issue has resolved. There is mention in the case report that adjustments to CPAP are needed, but it is unclear how a diagnostic PSG, without PAP titration, would help address that. The attended diagnostic PSG is considered not medically necessary, and the denial is upheld.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea grab bar.You asked the Plan to pre-approvea grab bar. You say that part of your therapy is learning how to walk again.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea grab bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair (K0813).You asked the Plan to pre-approvethe power wheelchair. You say that the power wheelchair is medically necessary.The Plandenied your request. The Plan says a power scooter was already provided and meets the enrollee's needs.The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when medically necessary.We asked our physician reviewer tocarefully 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 power wheelchair. Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer found the provided documentation does not clearly show objective evidence of postural instability or upper extremity disease or weakness to not be able to safely use a powered scooter.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 power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea power wheelchair (K0813)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forTc99m tetrofosmin and Regadenoson injection.You asked the Plan to waive the coinsurance forthe requested injections. You say that the cost of the injections should be included with the copayment for the nuclear stress test.The Plan denied your request. The Plan says the cost share for the injections were correctly billed separately from the cost share of the nuclear stress test.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 requested injections. Tc99m tetrofosmin and Regadenoson injection fall 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 forTc99m tetrofosmin and Regadenoson injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on November 10, 2020.You asked the Plan to pay for the surgical pathology 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. The Plan did not pre-approve the surgical pathology services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for surgical pathology services provided on November 10, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided on July 24 -July 25, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the hospital claim was paid and that these services were rendered at the same time. You say that this was part of that same hospitalization and should be paid.The Plan denied your request. The Plan says the services in dispute were not medically necessary.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department 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 not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided on July 24 -July 25, 2020