Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular risk assessment panel provided to the enrollee on August 18, 2020.
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomaticpatients with suspected or documented cardiovascular disease.
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 pay for the panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found cardiovascular risk assessment gene analysis was requested. This type of gene testing does not have sufficient support for general use in this type of patient as the test results would not significantly change the
treatment plan which would include dietary adjustments and other lifestyle adjustments and medication
optimization. Therefore, this request for cardiovascular gene testing 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 panel have not been met. Therefore, we decided that the Plan does not have
to pay for a cardiovascular risk assessment panel provided to the enrollee on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued inpatient hospital care provided from 5:45PM on October 17, 2020, through October 20, 2020.

You asked the Plan to pay for the continued inpatient care. You say that the entire admission was medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the enrollee was stabilized as of the evening of October 17, 2020, and authorization should have been requested for post-stabilization care.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 continued inpatient care. Our reviewer says that the enrollee is shown to have been medically stable by the date/time in question. Our physician reviewer found the enrollee is a 90-year-old man who was admitted to the hospital on 10/16/20 with a large right-sided cerebral infarct. Interventional radiology performed thrombus retrieval, and the enrollee's symptoms slowly improved. On 10/17/20, the enrollee felt better. The enrollee was drowsy, but easily arousable, with left facial weakness and 4+/5 left upper extremity weakness. The recommendation was to start aspirin, and Lipitor for secondary prevention. The enrollee was to continue work with therapies. Based on the available clinical documentation, the enrollee was stable to transfer by ambulance to an in-network hospital on 10/17/20.

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 continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the continued inpatient hospital care provided from 5:45PM on October 17, 2020, through October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary bike (E1399).

You asked the Plan to pre-approve a stationary bike. You say that you have to get in shape for your surgery you are having in 08/2021 so this is medically necessary. The Plan denied your request. The Plan says exercise equipment is not covered as it is not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stationary bike (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership for the calendar year 2020.
You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says payment is only eligible for reimbursement during the plan year in which the payment is made.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because payment is only eligible for reimbursement during the plan year in which the payment is made. Therefore, we decided that the Plan does not have to reimburse you for a gym membership for the calendar year 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided December 13, 2020.

You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied your request. The Plan says this item was provided following an unsolicited telehealth consult. There is no documentation of a physical exam or imaging to support that this item was needed.

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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for an orthosis (L0650) provided December 13, 2020.
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 feet are in pain. 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: Favorable

We decided that the Plan has to pre-approve a Rituximab (Truxima) injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication for this requested drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found the appropriate compendia documents that several small studies have demonstrated that Rituximab is an effective treatment for refractory myasthenia gravis with minimal adverse effects. Based on the medical records provided and the Medicare-approved major drug compendia, there is documentation that the requested drug is medically necessary, safe, and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-approve a Rituximab (Truxima) injection 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that you have a history with this physician, and you would like to stay with him. The Plan denied your request. The Plan says there are in-network providers available and there is not a gap issue.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional transportation trips.
You asked the Plan to provide coverage for additional transportation trips. The Plan denied your request. The Plan says you have used 34 of the 96 trips and have 62 remaining trips for 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The file shows that you have used 34 of the 96 trips and you have 62 remaining trips for 2021. Therefore, we decided that the Plan does not have to provide coverage for additional transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract lists the dental services that are covered. Diagnostic casts is not listed and therefore is not a covered service. You can find this information on pages 60 to 61 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) and the therapeutic parenteral drug, single administration (D9610).
You asked the Plan to pre-approve the dental services (D9243, D9239, D9610). You say that you need intravenous sedation due to your health conditions. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) and the therapeutic parenteral drug, single administration (D9610).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by out-of-network provider.
You asked the Plan to pre-approve physical therapy. You say that you would like to use this facility again because they helped your back get better. The Plan denied your request. The Plan says you must use network providers to get medical care and services when there are network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visual field assessment tech support (0397T).
You asked the Plan to pre-approve visual field assessment tech support. You say that the enrollee does not have the option to visit an in-network provider, was you are the only provider in the world to render these services. The Plan denied your request. The Plan says this device is experimental and investigational in nature. There is insufficient evidence to demonstrate that these devices improve clinical outcomes over standard monitoring approaches.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of visual field assessment tech support have not been met. Therefore, we decided that the Plan does not have to pre-approve visual field assessment tech support (0397T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient behavioral services provided on February 4, 2021
by an out of network (OON) provider.

You asked the Plan to pay for outpatient behavioral services. You say that you would like this claim
reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for
these 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 outpatient behavioral services provided on February 4, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three surgical extractions (D7210) provided on September
10, 2020.
You asked the Plan to pay for the extractions. You say that you can't afford this bill as you live on a fixed
income. The Plan denied your request. The Plan says they have agreed to cover the extractions; however, the
total cost for these services is $2,694. Your dental benefit has an annual maximum of $1,000 for
comprehensive services. The Plan has paid this full $1,000 amount, but you are responsible for the remaining
charges.
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, items or services that exceed the Plan's $1,000 annual limit are not covered under this benefit. Therefore, we decided that the Plan does not have to provide any additional payment for the surgical extractions (D7210) provided on September 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services (90837).

You asked the Plan to pre-approve the outpatient mental health services. You say that you have used this provider before and would like to continue. The Plan denied your request. The Plan says this type of provider is not covered under Medicare.

The Plan must follow Medicare rules. Medicare rules say that a licensed professional counselor is not eligible to participate in Medicare. 

We looked at the file and Medicare rules. The documentation shows the requested provider is a Licensed Professional Counselor. This type of provider is non-covered. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services (90837).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility visit (99309) provided January 4, 2021.

You asked the Plan to pay for the nursing facility visit. You say that the doctor entered you as a resident for 2 weeks from the hospital for rehabilitation. The Plan denied your request. The Plan says the cost share applied to the deductible correctly. Until you have paid the deductible amount, you must pay the full cost of your covered services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 combined in network and out of network deductible. This is the amount you have to pay out of pocket before the Plan will pay their share for covered services. 

The item or service you asked the Plan to pay for falls within the benefit category Skilled Nursing Facility (SNF) care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 combined in network and out of network deductible. This cost sharing is a contractual obligation that had not been met at the time the nursing facility visit was received on January 4, 2021. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility visit (99309) provided January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace provided on March 11, 2021.
You asked the Plan to pay for the back brace. You say that this was medically necessary, and all documentation supports payment. A telephone evaluation and management service is now allowed due to COVID waivers. The Plan denied your request. The Plan says there is no evidence of a visit between the enrollee and the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that for POD for items delivered via delivery service, documentation must include both the supplier invoice with description of the items delivered as well as confirmation from the delivery service. These documents must be linked by some clear method like the delivery service's package identification number or supplier's invoice number. In this case, while there is an invoice and delivery confirmation, these documents are not linked by any clear method. The invoice does not have the tracking number, nor does the delivery confirmation reference the invoice number. As such, POD is not valid per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the back brace provided on March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the CT scan. You say that you are appealing the denial. The Plan denied your request. The Plan says the provider is out-of-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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a CT scan to be provided by an out of network (OON) provider.