Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolaryn injection into the nasal cavity.

You asked the Plan to pre-approve the injection. You say that the enrollee has empty nose syndrome from damage to the turbinates. The Plan denied your request. The Plan says the procedure is not proven safe and effective at this time as the injection is not FDA-approved for this indication.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found Prolaryn is not FDA-approved for treatment or empty nose syndrome. Prolaryn injection into the nose is considered investigational and experimental, and is not considered standard treatment for this condition. Therefore it cannot be considered medically 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolaryn injection into the nasal cavity.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting, left and right (CPT Code 20611 x2) on July 13, 2020, provided to the enrollee.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our physician reviewer found the records show that the enrollee had bilateral ultrasound guided synvisc injections in the knees. There is no documentation of adequate conservative measures for knee pain such as steroid injections or recent physical therapy. Criteria for synvisc not met. Also, recent literature shows that synvisc is not effective for the treatment of knee degenerative joint disease. 

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 pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting, left and right (CPT Code 20611 x2) on July 13, 2020, provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on September 25, 2020.

You asked the Plan to waive the copayment for ambulance transport. You say that you were under the impression that the ambulance copayment would be waived if you were admitted. The Plan denied your request. The Plan says the copayment amount you are being charged is correct, because this ambulance trip was from a skilled nursing facility to your home and therefore the copayment waiver for a hospital admission does not apply.

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 $125 copayment for ambulance transportation. 

You have been asked to pay $125 copayment for ambulance transport. Ambulance transport falls within the Ambulance 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 copayment for ambulance transportation provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental consultation and dental extraction to be performed by an oral surgeon.

You asked the Plan to pre-approve dental services to be performed by an oral surgeon. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental services are only covered under your supplemental benefit when provided by a participating general dentist.

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, dental services to be performed by an oral surgeon are not covered. Dental services must be performed by a participating general dentist to be covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve a dental consultation and dental extraction to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical indication to support the need for this.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. 

To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. 

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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you are unable to pull an oxygen tank on a wheeled carrier because you use a wheeled walker. The medical records do not include documentation of ambulatory hypoxemia, but apparently ambulatory oxygen has already been approved. B tanks that can be filled from the stationary concentrator weigh less than a standard POC, and can be carried in a backpack or on the walker. 

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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural injection under sedation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of conservative therapy.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that supports the use of sedation at an out of network ambulatory surgery center. The request for sedation is 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural injection under sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vitamin/mineral injection and Vasopneumatic device therapy.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the best evidence does not indicate the effectiveness of the proposed treatment.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, based upon the documentation provided, the use of vitamin/mineral injections and vasopneumatic device for the treatment of neuropathy is experimental and investigational. Therefore, the service is not medically reasonable and necessary as defined by 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a vitamin/mineral injection and Vasopneumatic device therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. You say that these services were provided in good faith. The Plan denied your request. The Plan says these services could have been provided in-network. The Plan says that 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 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 psychotherapy services provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from August 21, 2020, to September 19, 2020.

You asked the Plan to pay for the SNF services. You say that the services that the enrollee received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled services on these dates of service.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 skilled nursing facility (SNF) care provided from August 21, 2020, to September 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation (A0429) provided on August 28, 2020.

You asked the Plan to waive the copayment for ambulance transportation. You say that this service was medically necessary and should be covered. The Plan denied your request. The Plan says this service is covered, but ambulance transportation services have a $325 copayment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for ambulance services. 

You have been asked to pay a $325 copayment for ambulance transportation. Ambulance transportation falls within the ambulance 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 copayment for the emergency ambulance transportation (A0429) provided on August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81292, 81407, 81408, 81479) provided June 30, 2020.

You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 codes 81292, 81407, 81408, & 81479 are not supported in the medical record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. Only one HCPCS code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81292, 81407, 81408, 81479) provided June 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).

You asked the Plan to pre-approve the personal care services. You say that the services are medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. 

We looked at the file and Medicare rules. The requested services are not covered by Medicare or the plan. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 1 additional filling and the unspecified preventive service provided on October 20, 2020.

You asked the Plan to pay for the dental services. You say that you were advised in the office that the services were covered at 100%. The Plan denied your request. The Plan says 2 fillings per calendar year are covered at 100%. The Plan says that the frequency limit for this service has been exhausted. The Plan also says that payment cannot be made for the unspecified preventive service as providers receive a separate stipend for this 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 frequency limit of 2 fillings per calendar year has been exhausted. The record shows that the Plan paid for the fillings for teeth # 11 and 21 that you received on this date of service, thus exhausting the benefit. 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 1 additional filling and the unspecified preventive service provided on October 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a scooter.

You asked the Plan to pay for the scooter. You say that the scooter will assist her in staying independent and is
medically necessary. The Plan denied your request. The Plan says there are no records supporting the
guidelines for coverage of a scooter have been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 scooter. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the documentation does not support that
the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily
living in the home. There is no documentation to show why the enrollee's mobility deficit cannot be helped
effectively by a walker or manual wheelchair in the home. The documentation does not reveal a detailed home
assessment indicating that the enrollee can safely maneuver the wheelchair in the home or that the requested
scooter will significantly improve mobility related activities of daily living in the home.

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 scooter have not been met. Therefore, we decided that the Plan does not
have to pay for a scooter.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care.

You asked the Plan to pay for SNF care. You say that the facility failed to request the proper authorization from
the Plan in a timely manner. You also say that the services were medically necessary for the enrollee. The Plan
denied your request. The Plan says that the enrollee was not enrolled in this Plan when
the enrollee was admitted to the SNF.

The Plan must follow Medicare rules. The rules say that in cases where the enrollee has enrolled or disenrolled
from the plan during the billing period, the SNF will split the bill and send the plan's portion to it and the
remaining portion to the appropriate Original Medicare contractor.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SNF care have been met. The Plan must provide coverage for the SNF skilled service while the
enrollee is enrolled in the plan until such time as the enrollee no longer needs the service and proper notice has
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for
skilled nursing facility (SNF) care.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a specialized wound treatment procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that osteomyelitis is a contraindicated diagnosis for this procedure.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the antimicrobial wound matrix PuraPly AM is indicated for the wound management in this enrollee. This wound had developed post right transmetatarsal amputation and has been already debrided to remove necrotic tissues.

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve a specialized wound treatment procedure for the enrollee.

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.