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

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 16, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36523 to support their denial. However, LCD L36139, L36129 and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129 and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that it would be detrimental to the enrollee's health if she is unable to continuously check her blood sugar levels throughout the day. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 you need IRF services. The Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an IRF.

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 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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.

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: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac nerve ablation.

You asked the Plan to pre-approve sacroiliac nerve ablation. You say that you would like the plan to reconsider their denial. 

The Plan denied your request. The Plan says the requested 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 sacroiliac nerve ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral sacroilitis. The enrollee takes Tizanidine, Diclofenac, Celebrex and Lyrica for pain. The enrollee has tried physical therapy and a home exercise program as well as over the counter medications. The enrollee had two sets of diagnostic lateral sacral branch blocks performed which produced 80% and 70% pain relief. The requested service is considered an experimental/ investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac nerve ablation.
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 requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 that the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. As a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that it is difficult to walk without the crow boot. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on February
24, 2021.

You asked the Plan to pay for the bone replacement graft. You say that these services were necessary, and your
provider told you that they would be covered. The Plan denied your request. The Plan says they have agreed
that you should not be held responsible for the tissue regrowth procedure (D4266); however, the bone
replacement graft procedure is not listed as a covered benefit under your dental plan. Payment cannot be made
for the bone replacement graft as it is clearly excluded from coverage.

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 the bone replacement graft (D7953) provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no
documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the
present acute care hospital. The enrollee does not require services at the LTACH that are not available at the
acute care hospital where he is currently receiving care. There are no services available at the LTACH that the
enrollee requires 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.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received February 16, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $250 copayment for Ambulance Services. You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 copayment for the ambulance transportation (A0429, A0425) received February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gravity-assisted traction device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 gravity-assisted traction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and the panoramic radiographic image (D0330) received on March 4, 2021.
You asked the Plan to pay for the 2D photographic image and the panoramic radiographic image. You say that you needed root canals on two teeth. The Plan denied your request. The Plan says there is no coverage for 2D oral/facial photographic image, and you have exhausted the benefit frequency for panoramic images.
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 or in excess of what is covered under this benefit. The Plan does not offer coverage for 2D oral/facial photographic images. The Plan limits coverage of either panoramic radiographic images or a complete series of radiographic images to one procedure every five years. You received, and the Plan covered, a complete series of radiographic images on this date of service. The benefit for the panoramic radiographic images was exhausted when you received this service on March 4, 2021. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and the panoramic radiographic image (D0330) received on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-network psychiatrist.

You asked the Plan to pre-approve these services. You say that you are not happy with the review you read for the network provider. 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 network facility has several providers from which you may receive services. 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 a non-network psychiatrist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for labs provided on February 5, 2021.

You asked the Plan to waive the copayment for labs. You say that you already paid your $15 copayment and disagree with the additional charges. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for labs. 

You received labs on February 5, 2021. Labs are not included in office visits and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $3.17, which is less than the $15 copayment. 

You have been asked to pay $3.17 for labs. Labs fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for labs provided on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer handle accessory.
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 were coded incorrectly.
The Plan must follow Medicare rules. The rules say that Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108. We looked at the file and Medicare rules. The requested transfer handle accessory was requested with code K0108; however, the correct code for these services is E0705. 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 transfer handle accessory.
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 IRF services are medically necessary. The Plan denied your request. The Plan says 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 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.

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 the dental services (D7210, D1110, D0150) received January
12, 2021 from an out-of-network provider.

You asked the Plan to pay for the dental services (D7210, D1110, D0150). You say that the requested services
should be paid for by the Plan. The Plan denied your request. The Plan says you must receive services innetwork.

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 dental services (D7210, D1110, D0150) received January 12, 2021 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).

You asked the Plan to pre-approve intermittent limb compression device. You say that this is medically necessary to assist with recovery after a hip replacement surgery. The Plan denied your request. The Plan says this is not a covered benefit, as it is a preventive service.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure (D2980) on tooth #18, and the unspecified preventive procedure (D1999) received January 25, 2021.
You asked the Plan to pay for the crown repair and the unspecified preventive procedure. You say that you received a new crown, not a crown repair. The Plan denied your request. The Plan says crown repairs 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. Dental records included with the case file indicate that the dental provider determined that a crown repair was appropriate for tooth #18. The dental record indicates you received a new crown on tooth #13 the following day on January 26, 2021. The provider billed a crown repair on January 25, 2021. Therefore, we decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure (D2980) on tooth #18, and the unspecified preventive procedure (D1999) received January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of a breast implant (19328).

You asked the Plan to pre-approve the removal of a breast implant. You say that the enrollee feels she has symptoms related to her implant based on her own research and has significant asymmetry. The Plan denied your request. The Plan says the requirements for coverage of an implant removal have not been met.

The Plan must follow Medicare rules. Medicare rules say that removal or revision of a breast implant is considered medically necessary when it is removed due to a mechanical complication of breast prosthesis, an infection or inflammatory reaction, or a complication of internal breast implant. 

We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has a mechanical complication of breast prosthesis, an infection or inflammatory reaction, or a complication of internal breast implant as described in the LCD. Asymmetry is not a covered indication for implant removal. Based on this information, we decided that Medicare rules for coverage of the removal of a breast implant have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of a breast implant (19328).