Persius/hicric huggingface dataset:
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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable but undergoing neurological work-up with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on medical condition still being worked up. 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a sigmoidoscopy provided on January 6, 2020.
You asked the Plan to waive the copayment for a sigmoidoscopy. You say that you already paid the $40
specialist copayment and disagree with the additional $42.51 charge. The Plan denied your request. The Plan
says that the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $40 copayment for each specialist visit.
You received a sigmoidoscopy on January 6, 2020. A sigmoidoscopy is considered an outpatient surgical
procedure. The record shows that you were already charged a $40 specialist copayment which covers surgical
services. Therefore, you cannot be asked to pay an additional $42.51 for the sigmoidoscopy.
The Plan says you must pay the coinsurance amount of $42.51 for a sigmoidoscopy. Based on the Plan
contract, however, you cannot be asked to pay more than a $40 copayment for specialist services. Therefore,
we decided that the Plan has to waive the copayment for a sigmoidoscopy provided on January 6, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two precision attachments (D5862 x2) and two endosteal implants (D6010 x2).
You asked the Plan to pre-approve the precision attachments and endosteal implants. The Plan denied your request. The Plan says these services are not covered 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 pre-approve the two precision attachments (D5862 x2) and two endosteal implants (D6010 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (A6549 and A6545)
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 and A6549 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 gradient compression stockings (A6549 and A6545)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on December 9, 2019.
You asked the Plan to pay for the services. You say that services from this provider have been paid in the past.
The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation a provider that has
opted out of the Medicare program. The file shows that this provider entered into a private contract with you
regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received on
December 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service the enrollee fell and was only semi-responsive. You felt he was having a heart attack and so you called 911. You say that the responders did a thorough job and you decided to decline transportation after the enrollee started to come around and began talking. You stated that you believe if you took him to the emergency room they would have run a few tests on him and sent him home with no care changes. You say that you feel this would have cost the Plan a lot of money. You stated that you thought you were saving the Plan money, and the resulting charge may cause you to wait too long to call for help in the event of another incident. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 14, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns (D2750) for tooth #19.You asked the Plan to pre-approve the crown for tooth #19. The Plan denied your request. The Plan says tooth #19 is missing and a crown cannot be placed on a missing tooth.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 crown for tooth #19 when the services are medically necessary and reasonable. 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 crown for tooth #19. Our reviewer says that the service is not medically necessary. Our physician reviewer found tooth #19 is missing from the dental arch and there is no ability to place a crown on tooth #19.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for tooth #19 have not been met.Therefore, we decided that the Plan does not have to pre-approve the crowns (D2750) for tooth #19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.
You asked the Plan to pre-approve a bath/shower chair. You say that a bath/shower chair is medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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-approve a bath/shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.You asked the Plan to pay for foot orthotics. You say that on a call with the Plan, the Plan representative stated that the foot orthotics would be covered.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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390, E0433) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an oxygen concentrator. You say that this equipment is not available in-network.The Plan denied your request. The Plan says this equipment is available from in-network providers and must be rented. 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.Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390, E0433) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvehigh intensity focused ultrasound (HIFU) treatment.You asked the Plan to pre-approveHIFU treatment. The Plan denied your request. The Plan says that this is an investigational service.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve HIFU treatment. Our reviewer says that the requested treatment is considered medically reasonable and necessary in this case. Our physician reviewer found that the medical records indicate that the enrollee has focal disease and is an excellent candidate for focal therapy. High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. HIFU was FDA approved for prostate gland ablation October 9, 2015. Numerous clinical studies cited below have demonstrated treatment efficacy that is comparable to surgery or radiation, but with a much lower risk of side effects such as impotence, incontinence and bowel injury.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HIFU treatment have been met.Therefore, we decided that the Plan has to pre-approvehigh intensity focused ultrasound (HIFU) treatment.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 pre-approve aGlucose Monitoring System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you want a continuous glucose monitor. The Plan denied your request. The Plan says criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The record shows you do not test four or more times a day or use insulin three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a s Glucose Monitoring System.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical insertion of the Vertiflex Superion Interspinous stabilization device (22869, 22870).You asked the Plan to pre-approve this service. You say that the service is medically necessary as the enrollee has lumbar spinal stenosis.The Plan denied your request. The Plan says that the requested service is not medically necessary and reasonable. 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex Superion Interspinous device is considered experimental as more research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pre-approve the surgical insertion of the Vertiflex Superion Interspinous stabilization device (22869, 22870)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection for the enrollee.You asked the Plan to pre-approvean electronic connection. The Plan denied your request. The Plan says that there is not a medical need to control these power options through the joystick.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 an electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The patient is not noted to have inability to utilize alesser device (lightweight manual wheelchair). Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of this item.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met.Therefore, we decided that the Plan does not have to pre-approvean electronic connection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 the requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mesial/distal wedge procedure for tooth #31.
You asked the Plan to pre-approve the mesial/distal wedge procedure. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve a mesial/distal wedge procedure for tooth #31.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve11 skilled nursing visits (G0299).You asked the Plan to pre-approve11 skilled nursing visits. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have skilled service needs.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 11 skilled nursing visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The documentation does not reveals evidence of complex wound care, IV medications, enteral feedings or other skilled needs beyond what was approved by the health plan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 11 skilled nursing visits have not been met.Therefore, we decided that the Plan does not have to pre-approve11 skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device provided to the
enrollee April 27, 2019.
You asked the Plan to pay for the intermittent compression device. You say that the claim should be paid. The
Plan denied your request. The Plan says documentation submitted did not include an itemized shipping/billing
invoice to indicate the specific supplies that were delivered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the
supplies provided in this case. The documentation submitted did not include an itemized shipping/billing
invoice to indicate the specific supplies that were delivered, only patient signed proof of delivery is available
but do not itemize what supplies where delivered. Therefore, the billed supply code cannot be verified.
Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device provided
to the enrollee April 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services were already paid for a different provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that billed services are not supported in the medical record. Specifically, the records provided do not show that the services in question were performed by the provider listed on the claim. These services were previously paid by the plan for a different provider for the same date of service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.You asked the Plan to pre-approve these services. You say that you want a screening for possible silent rupture of the implant.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules saythat MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a history of breast cancer with left mastectomy and reconstruction with silicone implant on June 10, 2015. You have had no problems since that time and a routine visit in January of 2020 with the plastic surgeon found no problems with the implant. The records do not show that you have had a recent mammogram confirming leakage of the implant. There is also no documentation of physical findings or symptoms of rupture. The MRI is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.