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

We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor Kit.
You asked the Plan to pre-approve the sensor. You say that the enrollee will continue to check their glucose; however, the enrollee would skip their insulin in the past. You state the enrollee does much better when they are on a Freestyle Libre and would like to get back on a sensor for better glucose control. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 meet the LCD criteria. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor Kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional routine transportation trips. The Plan denied your request.
The Plan says you have used all of the twenty (20) one-way trips for the year 2021.

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 20 one-way trips per year.

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. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (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 based on the medical records provided there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This patient does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This patient does not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.

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 skilled nursing facility (SNF) care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to sacroiliac (SI) joint (64625).
You asked the Plan to pre-approve radiofrequency ablation to SI joint. You say that this request is medically
necessary for your condition. The Plan denied your request. The Plan says the clinical value and effectiveness
of radiofrequency ablation to the SI joint have not been demonstrated in the peer-reviewed literature.
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 radiofrequency ablation to SI joint. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the requested procedure is considered experimental/investigational because
of the wide variation in efficacy reported in the literature. Therefore, the request is deemed not medically
reasonable or 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 radiofrequency ablation to SI joint have not been met. Therefore, we decided
that the Plan does not have to pre-approve radiofrequency ablation to sacroiliac (SI) joint (64625).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion or specialty drug administration (99601) provided from November 12, 2020, to December 14, 2020 by an OON provider.

You asked the Plan to pay for the home infusion or specialty drug administration (99601). You say that you made several attempts to contact the enrollee's primary care physician to have a referral submitted. You also say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that the services were referred by another non-participating provider, and prior authorization was not obtained.

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 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 home infusion or specialty drug administration (99601) provided from November 12, 2020, to December 14, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after June 14, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to need SNF care.
The Plan denied your request. The Plan says rules for SNF care are no longer 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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found while there are
identifiable skilled nursing service needs, there are no identifiable skilled therapy service needs. In addition,
you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or
intensity of service criteria for an inpatient basis 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after June 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0425, A0426) provided on February 21, 2021.
You asked the Plan to pay for the non-emergent ambulance services. You say that these transportation services were medically necessary. The Plan denied your request. The Plan says non-emergent ambulance transportation was not medically necessary, and another type of vehicle could have been appropriate for the enrollee.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the non-emergent ambulance services were not medically necessary on the date in question. Our physician reviewer found that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on February 21, 2021. Documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport or that the non-emergent ambulance transportation was medically reasonable and necessary for the patient.
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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0425, A0426) provided on February 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided February 22, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you just had a cleaning and exam, and the service should be covered. The Plan denied your request. The Plan says this service was previously covered in 2020 and therefore you were not yet eligible for coverage of the service at issue.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive oral exam once every three years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was covered August 24, 2020.
Based on this information, we determined that the Plan's frequency limit for coverage of the comprehensive oral exam was exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office or other outpatient visit (99205) and the ultrasound of soft tissues of head and neck (76536) provided January 25, 2021.
You asked the Plan to waive the copayment for the office or other outpatient visit and the ultrasound of soft tissues of head and neck. You say that you are being charged an incorrect copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $10 copayment for services obtained from a specialist.
You have been asked to pay a total cost share of $30 for the office or other outpatient visit and the ultrasound of soft tissues of head and neck. These services fall within the services obtained from a specialist and benefit Medicare-covered radiological diagnostic services categories. 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 office or other outpatient visit (99205) and the ultrasound of soft tissues of head and neck (76536) provided January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lesion removal provided by an out-of-network provider on March 1, 2021.
You asked the Plan to pay for the office visit and lesion removal. You say that you assumed there was an approved referral from your primary care physician because of your previous relationship. You say that you will not make any new appointments until this denial has been resolved. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 and lesion removal provided by an out-of-network provider on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based fillings (D2335) and periodontal scaling and root planing (D4346) provided on January 12, 2018 and April 12, 2018.
You asked the Plan to pay for the dental services. You say that you chose the first provider who was available and accepting new patients. These services were necessary for your dental and overall health and should be covered by the Plan. The Plan denied your request. The Plan says these services are not covered by your dental benefit. The Plan offers an additional optional dental benefit for an additional premium, which covers more services. However, you chose not to enroll in this option.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two oral exams, two dental x-rays, and two cleanings per year.
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 resin-based fillings (D2335) and periodontal scaling and root planing (D4346) provided on January 12, 2018 and April 12, 2018.
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 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 the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for a traumatic brain injury and cervical spine injury. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is noted to currently have a poor neurologic status and does not appear to be appropriate for ventilator liberation or decannulation. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, soft tissues of head and neck (76536) complete ultrasound, abdomen, real time with image documentation (76700) ultrasound, pelvic (nonobstetric) real time with image documentation (76856) ultrasound, breast, unilateral, real time with image documentation (76441) provided July 29, 2020 to August 12, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you do not think that it is right to receive this amount since they did not tell you first that you would have to pay so much. The Plan denied your request. The Plan says the claim was processed with the correct copayments applied per the Evidence of Coverage
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 $110 copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a physician's office or a freestanding facility. You have been asked to pay $414.26 ($110 + $110 + $84.26 + $110) for the diagnostic services. Since the allowed amount of CPT code 76856 was less than the copayment amount of $110, you are responsible for the lesser amount. The diagnostic services 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 the ultrasound, soft tissues of head and neck (76536) complete ultrasound, abdomen, real time with image documentation (76700) ultrasound, pelvic (nonobstetric) real time with image documentation (76856) ultrasound, breast, unilateral, real time with image documentation (76441) provided July 29, 2020 to August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the root canal (D3310) provided on February 17, 2021.
You asked the Plan to pay for the dental service. You say that you were referred to this provider. You say that
you were in immediate need of a root canal. You also say that you were not advised by the office that the
provider did not accept Medicare payments. The Plan denied your request. The Plan says that the provider in
this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services
performed by a provider who has opted out of Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the dental service by a contract provider. The file does not show that the Plan provided
notice that the dental service would not be covered. Under Medicare rules, this means the dental service is
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the root canal (D3310)
provided on February 17, 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.