Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a knee orthosis.

You asked the Plan to pre-approve a knee orthosis. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide enough medical records in order to determine if the enrollee meets Medicare criteria for the requested knee orthosis. Therefore, we decided that the Plan has to pre-approve a knee orthosis.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skin protectant.
You asked the Plan to pre-approve skin sealants, protectants, moisturizers, ointments, any type, any size
(A6250). You say that you have used this barrier before, and it was effective. The Plan denied your request.
The Plan says this wound care item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Skin protectants are not covered by Medicare. Therefore, we decided
that the Plan does not have to pre-approve a skin protectant
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ankle brace you received on March 29, 2021.
You asked the Plan to waive the coinsurance for the ankle brace. You say that the braces made for you did not work and weren't what your doctor wanted you to wear. You say that you should not have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that it confirmed with the brace provider that it provided the ankle brace that your doctor submitted on the order he sent to them.
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 20% coinsurance for prosthetic devices and supplies. We understand that the Plan assessed 20% coinsurance, stating that the brace you received is considered durable medical equipment. The Plan is not correct- braces are not considered durable medical equipment. They are considered orthoses that are paid for under the Prosthetic benefit. However, your Evidence of
Coverage states that Prostheses and Durable Medical Equipment have the same cost sharing associated with them. You have been asked to pay 20% coinsurance for the ankle brace. The ankle brace falls within the prosthetic devices and supplies benefit category. This copayment applies because you received the device that was ordered by your doctor. The fact that the brace did not work for you is not a justification for waiving the cost sharing as it is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ankle brace you received on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 30 trips to or from plan-approved locations, such as network physicians, medical facilities and pharmacies. The Plan says that you have used all 30 one-way trips to these types of covered locations and additional trips will not be approved.
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 a maximum of 30 one-way transportation trips per year to plan-approved locations, such as network physicians, medical facilities and pharmacies. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation for the requested locations. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the shoulder surgery represented by code 29826 provided on March 16, 2021.

You asked the Plan to pay for code 29826. You say that the medical records support the billing of code 29826. The Plan denied your request. The Plan says that the medical records do not support the billing of code 29826.

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 29826 is Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure). 

We asked our coder 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 code 29826. Our reviewer says that the medical records support the billing of code 29826. Our reviewer found the operative report does describe shoulder decompression with AC ligament release and acromioplasty. A shoulder decompression was performed. The code 29826 should be approved. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 29826 have been met. Therefore, we decided that the Plan has to pay for the shoulder surgery represented by code 29826 provided on March 16, 2021.

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: 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 service is medically necessary. The Plan denied your request. The Plan says the service 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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. Specifically, medically necessary services are available at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for knee arthroplasty.

You asked the Plan to pre-approve inpatient admission. The Plan denied your request. The Plan says this is 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 inpatient admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this procedure is routine, and the enrollee may safely have a 48-hour observational stay for the procedure. There is no need for inpatient admission for total knee surgery. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), elevated footrests (E1012), and an expandable controller (E2311, E2377, E2313) for a power wheelchair.
You asked the Plan to pre-approve the wheelchair features. You say that the features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that power elevated seat features are non-covered. Expandable controllers and powered footrests are covered only when 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 the wheelchair features. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found the notes do not show that the member has a condition, cast or brace preventing 90-degree flexion at the knee. The member does not have edema noted in physician exam. The powered footrests are not medically necessary. The enrollee is capable of using the standard power function switches and only one powered feature is eligible for coverage. The expandable controller is not medically necessary. Additionally, the power elevated seat feature is not covered under Medicare rules. 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 wheelchair features have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300), elevated footrests (E1012), and an expandable controller (E2311, E2377, E2313) for a power wheelchair
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance for disposable catheters you received on January 21,
2021.

You asked the Plan to waive the coinsurance for the catheters. You say that you have never had to pay for
catheters in the past and you were never advised that there was a change in your coverage. The Plan denied
your request. The Plan says that you were charged this coinsurance correctly.

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 says that for durable medical equipment
(DME), a $0 copay applies for DME less than $500. The contract also says that 20% coinsurance applies for
DME greater than or equal to $500. Records show that on the date of service in question, you received 600
disposable catheters. The allowed amount for these 600 catheters was $1,621.80, which equals $2.703 per
catheter. Your Plan contends that because the total catheter purchase was above $500, you are required to pay
20% DME coinsurance.

We do not find this argument persuasive for two reasons. First, it was inappropriate for the Plan to assess
DME cost sharing at all. Catheters and other urological supplies fall into the Prosthetics and Related Supplies
benefit, NOT DME. These catheters are not durable and CMS rules explicitly state that catheters are paid for
under the prosthetic device benefit. So, assessing DME cost sharing is not correct in this case. That being said,
the same cost sharing structure exists under the Evidence of Coverage for both DME and Prosthetics.

Second, we do not agree with the Plan's assertion that because the TOTAL cost of all 600 catheters you
received was higher than $500, that coinsurance should apply. A prudent layperson reading the Evidence of
Coverage would assume that the $500 limit would be based on a per-item price, not on the totality of items
received in a single order. Nowhere in the Evidence of Coverage does it state that the cost for purposes of
assessing cost sharing will be based on an aggregate of all ordered items. It is not reasonable to expect you to
know that an inexpensive item such as a disposable catheter would somehow trigger the cost sharing intended
for high-dollar items. Therefore, we decided that the Plan has to waive the coinsurance for disposable catheters
you received on January 21, 2021.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870, C1821).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the services are medically necessary. The Plan denied your request. The Plan says the procedure is investigational and is non-covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870, C1821).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OmniSeq Insight panel (500+ genes) for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says it has not been shown that the number of genes in the requested panel are reasonable and necessary to obtain necessary info for therapeutic decision making.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the medically reasonable and necessary criteria as established by Medicare 1862(a)1(A) have been met in this case. The requested OmniSeq Insight gene panel exceeds the enrollee's medical need.

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the OmniSeq Insight panel (500+ genes) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis or at an inpatient level in a skilled nursing facility setting. 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 admission have not been met. Specifically, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medically necessary services can be obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the services were ordered by the referring physician and the laboratory report shows the work that has been performed. The Plan denied your request. The Plan says the claim originally denied for not meet coding standards, but the services were not authorized.
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. The record shows the referring physician was also out-of-network. 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 laboratory work provided on March 17, 2021 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nexium 40mg tablets.
You asked the Plan to pre-approve Nexium. You say that Nexium is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for Coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexium 40mg tablets.
Benefits for Nexium may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights