Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the physical therapy services.

You asked the Plan to waive the copay for the services provided. You say that they were not collecting payment at the time of service due to COVID. The Plan denied your request. The Plan says the copay was applied per your plan benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copay for each Medicare-covered physical therapy visit.

You have been asked to pay a $40 copay for each physical therapy visit. The services fall within the outpatient rehab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the folding walker to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the folding walker. You say that you were previously authorized for this
equipment before switching plans. The Plan denied your request. The Plan says the provider is not 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/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
the folding walker to be provided by an out-of-network provider.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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 she is 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vascular study (CPT 93923 and 93924) for the
enrollee.

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your
request. The Plan says the guidelines do not support routine screening of asymptomatic patients with peripheral
artery disease, those with cardiovascular risk factors, or screening for all patients with peripheral artery disease
for asymptomatic atherosclerosis.

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 the study. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation sufficiently demonstrates that noninvasive Doppler testing of the lower extremities is
not a screening test in this case. At issue is the specific test that should be covered. As the enrollee has
documentation of absent pedal pulses and deformities of the toes there is sufficient documentation to support a
basic bilateral ABI with waveforms study, coded as 93922. This test was initially requested by the provider and
initially denied however only 93923 and 93924 are currently under review. CPT 93923 and 93924 cannot be
covered.

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 study have not been met. Therefore, we decided that the Plan does not have
to pre-approve a vascular study (CPT 93923 and 93924) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.

You asked the Plan to pre-approve these services. You say that you need transportation to medical appointments. The Plan denied your request. The Plan says the request exceeds the mileage limit.

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. The Plan covers up to 48 one-way trips per calendar year and each one-way trip must not exceed 50 miles of driving distance. 

We looked at your request, the records in the case file, and the rules. The file shows that you are requesting routine transportation for a total of 143 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
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's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for altered mental status, urinary tract infection, and COVID 19 infection. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says prior authorization was not obtained. The service was not urgent or emergent. There are multiple in-network providers within 30 miles of the patient's residence that could have rendered the service.

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 office visit provided on February 7, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning, two fillings, the oral exam, and the unspecified
preventive service provided on September 3, 2020.

You asked the Plan to pay for the dental services. You say that you have been seeing this dentist for the past
few years. You say that the Summary of Benefits says that you do not have to use an in-network provider. You
say that the services were necessary. You also say that you would like to be reimbursed for the services. The
Plan denied your request. The Plan says that the provider in this case has opted out of Medicare. The Plan says
that payment cannot be made for dental services that you receive from 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive from a
provider who has opted out of Medicare are not covered. The Evidence of Coverage clearly states that if you
use a provider that has opted out of Medicare you will not receive reimbursement. Therefore, we decided that
the Plan does not have to pay for the cleaning, two fillings, the oral exam, and the unspecified preventive
service provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services provided from March 1, 2012, to April 25, 2018.

You asked the Plan to reimburse you for the dental services. You say that you were never offered dental coverage when you signed up for this plan. You say that you never put in a claim since you were not covered. You say that you recently discovered that you had coverage of $250 yearly. You also say that you need this money at this time as a result of Covid-19. The Plan denied your request. The Plan says you did not have a routine dental benefit for your plan benefit from 2012 to 2018.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the dental services provided from March 1, 2012, to April 25, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of an incarcerated inguinal hernia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tolterodine.

You asked the Plan to pre-approve Tolterodine. You say that the enrollee has been stable on Tolterodine. The Plan denied your request. The Plan says outpatient prescription drugs are not covered by the enrollee's plan.

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 Tolterodine.

Benefits for Tolterodine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 enrollee has a history of stage Ib cervical cancer diagnosed in 2018. A surveillance PET scan has been ordered. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend the use of PET for routine imaging for stage I surveillance. The services are therefore 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 a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and foot, plastic, silicone or equal, heel stabilizer (L3170) provided September 4, 2020.

You asked the Plan to pay for the ankle foot orthosis and foot, plastic, silicone or equal, heel stabilizer. You say that these items were medically necessary. The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that the orthotics are covered when the criteria met in the Rules section are met. 

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 ankle foot orthosis and foot, plastic, silicone or equal, heel stabilizer. Our reviewer says that the orthotics are not medically necessary and reasonable. Our physician reviewer found there are no provider claim for the date of service nor does the provided documentation establish that a physician-patient encounter occurred. The documentation present does not indicate instability or a potential for functional benefit. In addition, the heel stabilizer is not covered when the ankle foot orthosis is not covered. 

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 ankle foot orthosis and foot, plastic, silicone or equal, heel stabilizer have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and foot, plastic, silicone or equal, heel stabilizer (L3170) provided September 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care (ex. intermittent therapy, restorative nursing therapy, LTC). 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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high activity knee control frame.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not support that the requested knee and high activity frame are medically necessary. A high activity knee control frame exceeds your medical needs. This is for K4 ambulators, and the documentation does not support that you are at the K4 ambulator level. The records show that you use forearm crutches and a wheelchair for ambulation. The criteria for coverage are not met and the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a high activity knee control frame.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit (99336) provided  by an out of network (OON) provider.You asked the Plan to pay forthe home visit. You say that these services were medically necessary.The Plan denied your request. The Plan says they do not cover out of network services, except in limited circumstances. The service in question was not urgent or pre-approved.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 forthe home visit (99336) provided  by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forroutine venipuncture provided by an out of network (OON) provider.You asked the Plan to pay forroutine venipuncture. You say that you do not agree with the Plan's denial.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were provided by an out-of-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 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 forroutine venipuncture provided by an out of network (OON) provider.