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

We decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920).
You asked the Plan to pre-approve the addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920). You say that the requested addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920) is medically necessary. The Plan denied your request. The Plan says the requested addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920) 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 the addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920). Our reviewer says that the requested addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920) is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920) is medically reasonable and necessary 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 addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920) have not been met. Therefore, we decided that the Plan does not have to pre-approve the addition, endoskeletal system, above knee or hip disarticulation, alignable system (L5920).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relistor for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Relistor for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid batteries received on December 17, 2020.
You asked the Plan to pay for hearing aid batteries. You say that you have been reimbursed for this item before, and you would like the Plan to pay for the item. The Plan denied your request. The Plan says the item was not obtained from a plan approved provider and is not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and supplies only when the Plan's approved providers are utilized. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aid batteries have not been met. Specifically, the request is for hearing aid batteries from an out of network provider. The Plan has network providers available to provide the items at issue. Therefore, we decided that the Plan does not have to pay for hearing aid batteries received on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on January 6, 2021.
You asked the Plan to waive the copayment for lab tests. You say that you have had these services in the past with no copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 copayment for lab tests provided by a freestanding lab. You have been asked to pay $20 copayment for lab tests. Lab tests 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 laboratory testing provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the regadenoson injection (J2785) provided October 1, 2020.

You asked the Plan to waive the coinsurance for the injection. You say that you received a bill from receiving a nuclear stress test. You were not aware you was receiving this medication prior to going in for your procedure and would like to appeal. The Plan denied your request. The Plan says the claim was processed and the correct cost share was 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 $47.34 20% coinsurance for Medicare Part B chemotherapy drugs and other Medicare Part B drugs for Medicare Part B prescription drugs. 

You have been asked to pay $47.34 20% coinsurance for Medicare Part B chemotherapy drugs and other Medicare Part B drugs for the injection. the injection falls within the Medicare Part B prescription drugs 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 coinsurance for the regadenoson injection (J2785) provided October 1, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's 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 osteomyelitis and dehydration. 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, in 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. 

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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve MRI. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because there is no documentation that a 6-week trial of provider-directed treatment has been tried and failed.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the enrollee meets the Medicare criteria for the requested MRI. Our physician reviewer found although the enrollee did not complete a course of pain medications along with physical therapy, the records indicate that the pain medications are not controlling the enrollee's pain and more concerning is that she is beginning to lose function of her left arm. This would make imaging with MRI for further evaluation medically appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehab facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for bacteremia/line infection. The enrollee is not intubated/ventilated. 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 long term care 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that this mechanical ventilator is indicated.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have chronic respiratory failure, both hypoxemic and hypercarbic, related to a combination of obesity-hypoventilation syndrome (OHS), heart failure with preserved ejection fraction, and possibly COPD or asthma. There are no pulmonary function studies to confirm the diagnosis of COPD, which would be unusual at your age. You do not have neuromuscular disease or thoracic restrictive disease. The treatment of OHS is CPAP or BiPAP. Medicare does not cover a ventilator for this diagnosis. Medicare does not cover a ventilator when used as BiPAP, which is the case here. Certain BiPAP devices can provide the AVAPS mode of support that has been ordered for the ventilator. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed rails.
You asked the Plan to pre-approve the rails. You say that you do not have space for a hospital bed. The Plan denied your request. The Plan says you do not have a hospital bed.
The Plan must follow Medicare rules. Medicare rules say that bed rails are only covered when used with a hospital bed. These rails cannot be covered as you do not have a hospital bed. Based on this information, we decided that Medicare rules for coverage of the rails have not been met. Therefore, we decided that the Plan does not have to pre-approve bed rails.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on June 14, 2019.

You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.

The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service June 14, 2019. 

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic visits provided from November 19, 2020, to December 14, 2020.
You asked the Plan to waive the copayments for chiropractic visits. You say that you were previously informed that your copayment would be $0 due to COVID-19. The Plan denied your request. The Plan says the copayment amounts you are being charged is correct.
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 copayment for each covered chiropractic visit. There were 3 visits, resulting in a total copayment obligation of $60. You have been asked to pay $20 copayment for chiropractic visits. Chiropractic visits fall within the Chiropractic Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for chiropractic visits provided from November 19, 2020, to December 14, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's 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 closed head injury, rib fractures and fractured spleen after a motorcycle accident. 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, in 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. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment (A4615, E1357, E1390, S9999) provided
May 15, 2020.

You asked the Plan to pay for the oxygen equipment. You say that the oxygen equipment was medically
necessary. The Plan denied your request. The Plan says purchased oxygen equipment is not covered.

The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for
coverage.

We looked at the file and Medicare rules. The oxygen equipment was purchased Based on this information, we
decided that Medicare rules for coverage of the oxygen equipment have not been met. Therefore, we decided
that the Plan does not have to pay for oxygen equipment (A4615, E1357, E1390, S9999) provided May 15,
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transportation provided on October 16, 2020.
You asked the Plan to pay for air ambulance. You say that this was an emergency request. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because air ambulance service was
not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate.
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 air ambulance. Our reviewer says that this
transportation does not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee was
stable in condition and it would be medically appropriate to have had an evaluation and diagnosis at an
emergency department where it could be decided what type of center would be best for treatment of the
enrollee's condition. The records do not support the medical necessity of air ambulance service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of air ambulance have not been met. Therefore, we decided that the Plan does not
have to pay for air ambulance transportation provided on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 11, 2020.

You asked the Plan to pay for the dental service. You say that you feel that this claim denied in error. The Plan denied your request. The Plan says periodontal maintenance is not listed as 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 pay for the periodontal maintenance (D4910) provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on December 21,
2020.

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration
because these providers saw the member for different issues. The Plan denied your request. The Plan says code
99233 is a column II to column I code 99223 and was billed by same provider.

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 the
subsequent hospital care has a bundled relationship with code 99223 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 subsequent hospital care (99233) provided on
December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (36465) provided on July 29, 2019.

You asked the Plan to pay for the injection. You say that the services were medically necessary. The Plan
denied your request. The Plan says there were network providers available.

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 an injection (36465) provided on July 29, 2019.