Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601) provided on November 17, 2020.

You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I and is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acutehospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia, urinary retention and lower extremity wounds. Medical problems are stable.

There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ECG and breathing capacity test provided on February 9, 2021.

You asked the Plan to waive the copayment for the ECG and breathing capacity test. You say that the tests were part of a routine preventive care exam and the copayment should be eliminated. The Plan denied your request. The Plan says the copayment applied 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 clearly says that you must pay $35 for each outpatient x-ray, diagnostic procedure & test.

You have been asked to pay a $35 copayment for the ECG and breathing capacity test. The ECG and breathing capacity test fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 ECG and breathing capacity test provided on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor and supplies.
You asked the Plan to provide a therapeutic continuous glucose monitor and supplies. You say that the enrollee has had some medication changes that will require checking blood sugars more often than usual. The Plan denied your request. The Plan says criteria is not met for a 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 use insulin with at least three daily injections nor requires 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 a therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins
when required (D2950).
You asked the Plan to pre-approve the crown and core buildup. You say that it is not advised to have any kind
of metal in your mouth, and you would like these services to be approved for coverage. The Plan denied your
request. The Plan says these services are not covered benefits.
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 a
crown (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (CPT code J7325), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee has not tried and failed the preferred step therapy device(s): Monovisc
and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 medication. Our physician reviewer
found the enrollee has no tried and failed the required drug(s). The documentation does not support that
Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the
enrollee 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 the medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc (CPT code J7325), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services (T1019) provided on August 9, 2020.

You asked the Plan to pay for the personal care services. You say that the provider was not notified that the enrollee switched coverage. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the personal care services (T1019) provided on August 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the unspecified preventive service (D1999), and the root canal (D3330) provided from October 20, 2020, to November 5, 2020.
You asked the Plan to pay for the dental services. You say that you received a bill for $1,389.92. You say that the plan was supposed to pay 50% of the cost. You say that the plan only paid $315.08. You say that if you had known that this provider was out of network, you would have gone elsewhere for in network services. You also say that you should not be responsible for more than 50% of the cost. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network providers are allowed to balance bill members for the difference between their billed amount and the plans paid amount.
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 and the limited oral evaluation and root canal are listed as covered, they were performed out of network. The Evidence of Coverage clearly states that services performed out of network may cost more.
Additionally, the unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the unspecified preventive service (D1999), and the root canal (D3330) provided from October 20, 2020, to November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings (A6549) and adhesive or non-adhesive; disk or foam pad (A5126).
You asked the Plan to pre-approve the compression stockings and foam pad. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee does not meet the criteria since the enrollee needs compression stockings for the arm and the requested item is for compression stockings for the legs.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 and A5126 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings (A6549) and adhesive or non-adhesive; disk or foam pad (A5126).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from October 19, 2020, to
November 18, 2020.

You asked the Plan to pay for the SNF services. You say that the enrollee was informed that the services would
be covered by his insurance policy. The Plan denied your request. The Plan says the enrollee did not receive
skilled nursing facility services, but instead received custodial care which is not a covered benefit.

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 pay for the SNF services. Our reviewer says that the
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill,
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing
and/or skilled therapy on an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the SNF services provided from October 19, 2020, to November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you are unable to stand in the shower without proper support. The Plan denied your request. The Plan says this item is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device remains 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on September 22, 2020.

You asked the Plan to pay for the preventive procedure. You say that you believe this service should be
covered. The Plan denied your request. The Plan says this service is not covered.

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
preventive procedure provided on September 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the echocardiography testing provided on January 26, 2021.

You asked the Plan to waive the copay for the testing services. You say that you never had to pay for the test in the past. The Plan denied your request. The Plan says the cost share was applied 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 clearly says that you must pay a $35 copay for each outpatient diagnostic procedure and test. 

You have been asked to pay $17.04 for the testing services. Because the amount is less than the $35 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the echocardiography testing provided on January 26, 2021.
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 this is the best level of care. The Plan denied your
request. The Plan says that the documentation does not support that your functional status requires an intensive
rehabilitation therapy program provided on an inpatient rehab unit.

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 non-operative management of
low back pain. 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 the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that the enrollee was already and established patient with the requested specialist and there is no in-network specialist who can handle this case. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 23, 2020 by an out of network provider.

You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization.

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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 23, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two retainer crowns (D6750 x2) and two pontics (D6240 x2).
You asked the Plan to pre-approve the retainer crowns and pontics. You say that you would like these services to be approved for coverage. The Plan denied your request. The Plan says these services are not covered.
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 two retainer crowns (D6750 x2) and two pontics (D6240 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Group 3 power wheelchair accessories.

You asked the Plan to pre-approve Power wheelchair expandable controller (E2377), Power wheelchair expandable controller harness (E2313), Power wheelchair electronic connection (E2311), power seat elevation feature (E2300), or K0108 bag hooks. You say that the enrollee needs these Group 3 power wheelchair accessories. The Plan denied your request. The Plan says bag hooks do not serve a medical purpose, power seat elevation features are not covered, and an expandable controller is not necessary because the approved power options come with their own switches.

The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.
The file shows that upper limb strength and function are adequate for the enrollee to control the power options using their own switches which are included in the allowance of the power options. The bag hooks do not serve a purpose that is primarily medical in nature, and the power seat elevation feature is not covered by Medicare.

This means that Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve these Group 3 power wheelchair accessories.