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

We decided that the Plan does not have to pre-approve a bone replacement graft on tooth #3 (D7953).
You asked the Plan to pre-approve the bone replacement graft. You say that this service is medically necessary. The Plan denied your request. The Plan says this procedure 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 a bone replacement graft on tooth #3 (D7953).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex device. You say that you believe that this procedure meets the Medicare requirements for medical necessity. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective to treat back pain. Medicare does not cover experimental and investigational services.

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 the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and power searing system to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a power wheelchair and power searing system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.

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 power wheelchair and power searing system to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insulin pen.

You asked the Plan to pre-approve the insulin pen. You say that you have used a sample pen and want to continue using one. The Plan denied your request. The Plan says the insulin pen is not covered under the enrollee's Medicare Part B benefit.

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-approve the insulin pen.

Benefits for the insulin pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator rendered on December 3, 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 is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. The claim does not indicate that a separate ventilator was rented. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home ventilator rendered on December 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for chartered air ambulance transportation provided on December 21, 2019.

You asked the Plan to pay for air ambulance. You say that this transportation was medically necessary for you to return home following emergency heart surgery. The Plan denied your request. The Plan says the denial of payment for this transportation is correct, because this transportation was to return home and not to receive emergency or critical care services.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 air ambulance. Our reviewer says that this transportation does not meet the Medicare criteria for coverage. Our physician reviewer found there is no documentation that you suffered from an illness or injury that contraindicated transportation by any means other than ambulance. You were stable as of December 21, 2019, and a note from December 17, 2019 reported that you were doing great. The documentation does not show that your condition was such that the time needed to transport you by ground, or the instability of transportation by ground, posed a threat to your survival or seriously endangered your health. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance have not been met. Therefore, we decided that the Plan does not have to pay for chartered air ambulance transportation provided on December 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); respiratory virus services coded 87633 provided on September 1, 2020.

You asked the Plan to pay for the infectious agent detection by nucleic acid (DNA or RNA); respiratory virus 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 covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The infectious agent detection by nucleic acid (DNA or RNA); respiratory virus services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); respiratory virus services coded 87633 provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis coded L3960 provided on September 14, 2020.

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item rendered is 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 L3960 is shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes fitting and adjustment. 

We find that CPT code L3960 is not supported in the medical record. Specifically, the documentation does not support a claim for this enrollee from the ordering physician. The documentation does not support that the enrollee ever saw this enrollee. Based on this information, we decided that Medicare rules for coverage of the shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis coded L3960 provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network podiatrist.

You asked the Plan to pre-approve these services. You say that you can't walk or drive with your right foot. The Plan denied your request. The Plan says the services are available from network providers.

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. The Plan confirmed that the network providers are able to treat your condition. 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 referral to an out-of-network podiatrist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic supplies to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve prosthetic supplies. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available 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 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 prosthetic supplies to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the health center visit (99213, G0467) provided on October 12, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the health center visit. You say that the Plan should cover the service. The Plan denied your request. The Plan says OON criteria for the service are not met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the health center visit (99213, G0467) provided on October 12, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental personal protective equipment (PPE) provided on October 20, 2020.

You asked the Plan to pay for dental PPE. You say that this preventive equipment is being covered under medical insurance, so it should be for a dentist. The Plan denied your request. The Plan says the denial of payment for this charge is correct, because dental PPE is not covered by the Plan's dental benefits.

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 dental personal protective equipment (PPE) provided on October 20, 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 you were advised by your doctor to wear an orthopedic shoe. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 31, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on October 19, 2020.

You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you feel like you should only have to pay for one night in the hospital. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient surgery. 

You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $20,129.97. The total amount you are being asked to pay is $4,025.99 ($20,129.97 x 20% = $4,025.99). The surgery that was provided is considered outpatient; therefore, the correct coinsurance has been applied. An outpatient surgery falls within the outpatient surgery 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 an outpatient surgery provided by a participating provider on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from September 4, 2020 to October 3, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization for agitation and aggression. He received oral and topical medications and had stable vital signs. He received physical therapy in the SNF and an occupational therapy evaluation. Upon evaluation, he reached an independent level with functional mobility with no assistive device. He required varying assist with activities of daily living. He had no skilled nursing or skilled therapy needs. He did not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee did not require the necessary services on
an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from September 4, 2020 to October 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the dental crown provided on July 30, 2020.

You asked the Plan to adjust the coinsurance for the dental crown. You say that you would like the Plan to lower your coinsurance. The Plan denied your request. The Plan says you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

You are responsible for the difference between the in-network fee schedule and the dentist's charges when visiting an out-of-network dentist. 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 adjust the coinsurance for the dental crown provided on July 30, 2020.