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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the 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 is receiving appropriate inpatient acute care.

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 acute care hospital for new onset right upper extremity weakness and decreased responsiveness. He was found to a new contralateral right medullary stroke. He remains with dysphagia, bilateral weakness and severe dysarthria. He is receiving appropriate care at the present facility. He does not require services at the LTACH that are not available at the present facility where he is currently receiving care. There are no services available at the LTACH that he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdominal CT scan (74160) and a chest CT scan (71260) performed on August 14, 2020.
You asked the Plan to waive the copayment for an abdominal CT scan and a chest CT scan. You say that you have never heard of this copayment requirement before and have never been billed $200 for a CT scan. The Plan denied your request. The Plan says the correct copayment was 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 $200 copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as CT scans.
You have been asked to pay a $200 copayment for an abdominal CT scan and a chest CT scan. An abdominal CT scan and a chest CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 an abdominal CT scan (74160) and a chest CT scan (71260) performed on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 7,
2021.

You asked the Plan to pay for the dental service. You say that you were advised that the provider still accepted
your plan as they did 2 years prior. You say that you never received a provider directory. You also say that this
service should be paid at the in network rate. The Plan denied your request. The Plan says limited oral
evaluation is not listed as a covered service.

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 limited oral evaluation is not
among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that
the Plan does not have to pay for the limited oral evaluation (D0140) provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an OON provider.
You asked the Plan to pre-approve OON services. You say that no one else is willing to help the enrollee. The
Plan denied your request. The Plan says the requested services are available in-network.
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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items out of network. Therefore, we decided that the Plan does not have to pre-approve a
power wheelchair to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for Sandostatin LAR Depot.

You asked the Plan to waive the cost share for the requested services. The Plan denied your request. The Plan
says a tier exception is not available for drugs covered by Part B.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

We looked at the file and the rules. Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs. The medication falls within the Medicare Part B
prescription drugs benefit category. This is 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 cost share for Sandostatin LAR Depot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extractions (D7140 x 3) and the limited oral evaluation (D0140) provided on December 29, 2020.

You asked the Plan to reimburse you for the dental services. You say that you were never told about an out of network provider. You also say that you were told that you would be reimbursed for the $456. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a provider who has 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. The Plan covers the dental service when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, dental services performed by a provider who has opted out of Medicare are not payable. Therefore, we decided that the Plan does not have to reimburse you for the extractions (D7140 x 3) and the limited oral evaluation (D0140) provided on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces (L1851), suspension sleeves (L2397), and a back brace (L0648) provided on December 11, 2020.

You asked the Plan to pay for knee braces, suspension sleeves, and a back brace. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of knee braces, suspension sleeves, and a back brace have not been met. Therefore, we decided that the Plan does not have to pay for knee braces (L1851), suspension sleeves (L2397), and a back brace (L0648) provided on December 11, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that according to the
enrollee's clinical documentation, she is currently at a standby to contact guard level of assistance for transfers
and some activities of daily living. She is able to walk a household gait distance of forty feet with a wheeled
walker. She is currently medically stable. She does not have any intravenous (IV) medications or complex
wound care needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that SNF
care is medically necessary. Our physician reviewer found based on the documentation provided, it is my
opinion that the enrollee qualifies for SNF coverage. The enrollee does not have documented skilled nursing
needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her
baseline. It has not yet been shown that the enrollee has reached a plateau in function. A trial of daily skilled
services is reasonable to establish a maintenance program, prevent deterioration of the enrollee's condition and
assess her long-term needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.

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 pay for the automatic external defibrillator provided by an out-of-network provider on September 5, 2020.
You asked the Plan to pay for the automatic external defibrillator. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 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 automatic external defibrillator provided by an out-of-network provider on September 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December
14, 2020, through December 24, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were sent home between
stays due to no surgery room being available. You say that you should not have to pay $1,950 twice. The Plan
denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay $325 per
day, days 1-6, and $0 for additional hospital days for each in-network, Medicare-covered hospital
admission/stay.
You have been asked to pay a $1,950 copayment for the inpatient stay ($325/day x 6 days = $1,950). The
inpatient stay falls within the "Inpatient hospital care" benefit category. The records show this was a separate
admission. 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 inpatient stay provided from December
14, 2020, through December 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and report on referred slides prepared elsewhere services coded 88321 provided on November 11, 2020.

You asked the Plan to pay for the consultation and report on referred slides prepared elsewhere services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the consultation and report on referred slides prepared elsewhere services have not been met. Therefore, we decided that the Plan does not have to pay for the consultation and report on referred slides prepared elsewhere services coded 88321 provided on November 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services coded 97110 provided on March 5,
2020.

You asked the Plan to pay for the therapy services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows
that this service was performed by a physical therapy assistant in the home setting. This means there is a more
appropriate code to be billed for this service. Based on this information, we decided that Medicare rules for
coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay
for the therapy services coded 97110 provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 you were hospitalized for acute hypoxic respiratory failure secondary to Covid-19 and
Klebsiella pneumonia. You remain on warm high flow oxygen therapy. You are receiving appropriate care at
the present acute care hospital. You do not require services at the LTACH that are not available at the acute
care hospital where you are currently receiving care. There are no services available at the LTACH that you
require that are not available at the health care setting being offered by the health plan. Therefore, the requested
LTACH services are not medically 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the compression socks help with your pain levels. The Plan denied your request. The Plan says the items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.

You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not 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 a Superion interspinous spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the Superion spacer device is experimental. More research is needed to
show safety and efficacy of the device.

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 Superion interspinous spacer have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (22869 and 22870).
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is experimental and 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 Vertiflex Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the elements of the coverage criteria for this service, recommended by The Food and Drug Administration, are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device have not been met. Specifically, the service requested is considered experimental and not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (22869 and 22870).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services rendered on October 16, 2019.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The file shows that the claim for these services were not billed with
the proper POS code to reflect services in the enrollee's home setting.

Therefore, we decided that the Plan does not have to pay for the home visit services rendered on October 16,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Guardian Sensor 3 CGM and supplies.

You asked the Plan to pre-approve the CGM and supplies. You say that you are a type 1 diabetic, and need the
sensor for your insulin pump to take your medication. The Plan denied your request. The Plan says there is no
Medicare benefit or health plan added benefit for continuous glucose monitors or their supplies if it is a nontherapeutic
CGM. The Plan also says that these items cannot be covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CGM supplies have not been met. Specifically, the record indicates that the requested supplies
are for use with a non-therapeutic CGM. Supplies for use with non-therapeutic CGMs are not covered by
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the Guardian Sensor 3
CGM and supplies.