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

We decided that the Plan does not have to pre-approve root canal retreatment (D3346).

You asked the Plan to pre-approve root canal retreatment. You say that you need this service before you can receive heart surgery. The Plan denied your request. The Plan says this is not a covered service.

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 root canal retreatment (D3346).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses with suspension sleeves (L2397, L1833)
provided on September 24, 2020.

You asked the Plan to pay for knee orthoses with suspension sleeves. You say that these services were
medically necessary for the enrollee. The Plan denied your request. The Plan says the records do not establish
that the provider examined the enrollee before the services were ordered.

The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination
of the beneficiary and objective description of joint laxity.

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 knee orthoses with suspension sleeves. Our
reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there
is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective
documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the
base item 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 knee orthoses with suspension sleeves have not been met. Therefore, we
decided that the Plan does not have to pay for knee orthoses with suspension sleeves (L2397, L1833) provided
on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness panel provided on August 11, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says predictive
screening testing is not a Medicare 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 testing at issue was requested for screening purposes. The records do not show that the testing was ordered
for a specific diagnosis or treatment strategy. Medicare does not cover this testing for screening purposes.
Therefore, we decided that the Plan does not have to pay for the wellness panel provided on August 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 18, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that the representative gave you false information and for this reason the enrollee should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $195 copayment for ambulance services. 

The enrollee has been asked to pay a $195 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on August 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve these services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when four factors 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided daily skilled services are not required. The records do not show that you require the services on an inpatient basis. The medical records do not show you require skilled inpatient services on a daily basis. Medicare coverage criteria are not met. 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 skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the weight bench purchased on September 6, 2020.
You asked the Plan to reimburse you for the weight bench. You say that you had to stop going to the gym because of COVID and you feel there should be no date involved for reimbursement. The Plan denied your request. The Plan says prior purchased made before the benefit start date of October 1, 2020 do not qualify.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan allowed enrollees to apply their Wellness Allowance toward the purchase of fitness equipment. The benefit period was October 1, 2020 to December 31, 2020. The Plan's rules for coverage of gym benefits have not been met because your weight bench purchase was made before the benefit period started. Therefore, we decided that the Plan does not have to reimburse you for the weight bench purchased on September 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Urolift Device.

You asked the Plan to pre-approve the Urolift Device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 Urolift Device. Our reviewer says that the Urolift device is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not include documentation of a prostate volume. Urolift is indicated when the prostatic volume is than or equal to 80 ml. 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 Urolift Device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Urolift Device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 23, 2020.
You asked the Plan to pay for the dental service. You say that this was your third oral exam for the year. You say that this was not a routine exam, but an exam for a problem. You also say that you feel that this claim should be paid. The Plan denied your request. The Plan says 2 oral exams are covered per year. The Plan also says that the frequency limit for oral exams has been exceeded.
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 frequency limit of 2 oral exams per year has been exceeded. The record shows that the Plan paid for oral exams that you received on February 3, 2020, and August 13, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.

You asked the Plan to pre-approve a CardioMems device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.

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 a CardioMems device. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMems device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMems device is uncertain at this time according to leading authorities and is not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device is still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMems device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the six additional intraoral periapical x-rays provided on
October 19, 2020.

You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you should not be held
responsible for these charges. The Plan denied your request. The Plan says benefits for this service had been
satisfied and the frequency limitation had been exceeded.

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, intraoral x-rays are limited to one
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on October
19, 2020, which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. Therefore, we
decided that the Plan does not have to pay for the six additional intraoral periapical x-rays provided on October
19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on May 21, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says a more appropriate code exists for the procedure described.
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 24301 is Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331). 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 services provided. Our physician reviewer found that code 24301 is not supported in the medical records. Specifically, the operative report does not document any evidence of a muscle or tendon transfer procedure. 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on May 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit to the emergency department (99285) provided on November 3, 2020.
You asked the Plan to waive the copayment for the emergency care. You say that you would not have had to go to the emergency department if your doctor had given you the MRI you requested. You say that after the emergency department provided an MRI, you were able to get a more accurate diagnosis and proper care, but you should not have had to go to the emergency room to do so. The Plan denied your request. The Plan says they understand your concerns and have forwarded your quality of care concern to the appropriate organization. However, emergency services require a $110 copayment.
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 $110 copayment for emergency care. You have been asked to pay a $110 copayment for the emergency room visit. An emergency room visit falls within the emergency care 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 visit to the emergency department (99285) provided on November 3, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. The Plan has indicated that they have forwarded your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 19 additional physical therapy sessions for the enrollee.
You asked the Plan to provide coverage for additional physical therapy. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 provide coverage for additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional 19 sessions of therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that her functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The Plan approved one session for caregiver training. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy have not been met. Therefore, we decided that the Plan does not have to provide coverage for 19 additional physical therapy sessions for the enrollee.
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 inpatient rehabilitation is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 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 repair of a hip fracture after a fall Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Medicare coverage criteria are not met. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tub transfer bench and adjustable bed rail provided on May 31, 2020, to August 29, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the tub transfer bench and adjustable bed rail. You say that you would like this claim reprocessed and approved for payment for medical necessity. The Plan denied your request. The Plan says prior authorization is required for all OON 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 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 tub transfer bench and adjustable bed rail provided on May 31, 2020, to August 29, 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 long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan without contrast (70450) provided on October 10, 2020.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.
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, we have confirmed that code 70450 scan has a bundled relationship with code 70496, which was billed by the same provider for the same date of service, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan without contrast (70450) provided on October 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 27, 2020 to July 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the infusion services. You say that you were previously told that no authorization was required. You also say that you are showing as out of network, but are in network. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that the services provided were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. 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 medical services provided on June 27, 2020 to July 2, 2020 by an out of network (OON) provider.