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

We decided that the Plan does not have to pay for bilateral suspension sleeves (L2397).

You asked the Plan to pay for bilateral suspension sleeves. You say that this item was medically necessary. The Plan denied your request. The Plan says this service is not eligible for coverage.

The Plan must follow Medicare rules. Medicare rules say that a suspension sleeve is not eligible for coverage when the base orthosis 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 bilateral suspension sleeves. Our reviewer says that the requested items were not medically necessary and reasonable. Our physician reviewer found that the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. Therefore, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for bilateral suspension sleeves (L2397)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical extraction of impacted teeth (D7240), deep sedation/general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9612).

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.

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 the surgical extraction of impacted teeth (D7240), deep sedation/general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9612).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighty-five (85) additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you exhausted your benefit.

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. 

We looked at your request, the records in the case file, and the rules. Based on this information, you exhausted your twenty-four (24) one-way trips benefit. The 25th trip and beyond is not a covered benefit. Your 2021 EOC states the Plan covers routine transportation for up to twenty-four (24) one-way trips per calendar year. Therefore, we decided that the Plan does not have to pre-approve eighty-five (85) additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have pay for an excision in mouth.

You asked the Plan pay for an excision in mouth. You say that you were referred to the provider and you do not understand why the claim would be denied. The Plan denied your request. The Plan says the claim was denied because the service was rendered by a Medicare Opt out provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have pay for an excision in mouth.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Procrit (J0885) and Octreotide (J2354).

You asked the Plan to pre-approve Procrit and Octreotide. You say that you need these drugs to be approved. The Plan denied your request. The Plan says that you are not receiving myelosuppressive chemotherapy at this time. The Plan also says that the treatment of anemia with with these drugs is not in compliance with the Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD).

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Procrit and Octreotide. Our reviewer says that Procrit (J0885) and Octreotide (J2354) are medically reasonable and necessary for you. Our physician reviewer found the requested use of Procrit (J0885) and Octreotide (J2354) are not FDA-approved for your diagnosis. Our reviewer found that the use of Procrit (J0885) and Octreotide (J2354) is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer also found that the use is not listed as not indicated, not supported, or not recommended in any of the compendia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit and Octreotide have been met. Therefore, we decided that the Plan has to pre-approve Procrit (J0885) and Octreotide (J2354).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen oxygen generator.

You asked the Plan to pre-approve an Inogen oxygen generator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not payable for purchase.

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. Review of the file shows that you are requesting the purchase of an Inogen oxygen generator for the enrollee. The purchase of this item is not covered. Based on this information, we decided that Medicare rules for coverage of an Inogen oxygen generator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Inogen oxygen generator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device.

You asked the Plan to pre-approve the Vertiflex device. You say that you strongly believe that coverage should be provided under the Plan, which based on the guidelines that they must comply with Original Medicare regulations. The Plan denied your request. The Plan says this procedure considered experimental, investigational or unproven as it is still being studied to determine safety and efficacy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement scooter.

You asked the Plan to pre-approve a replacement scooter. You say that you need a scooter because you have knee pain when you walk. The Plan denied your request. The Plan says your doctor's clinical notes show that you are moderately independent with all mobility and transfers.

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. 

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement scooter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services.

You asked the Plan to pay for the surgical pathology. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they 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 did not pre-approve the
surgical pathology services. 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 surgical pathology services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a participating provider.

You asked the Plan to waive the copayment for an urgent care visit. You say that this was a straightforward visit, and you believe this should be covered by the Plan. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $25 copayment for urgently needed services/in-network/urgent care center.

You have been asked to pay a $25 copayment for an urgent care visit. The correct copayment has been applied to the services that were provided. An urgent care visit falls within the urgently needed services/in-network/urgent care center 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 an urgent care visit provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral nutritional supplements.

You asked the Plan to pre-approve oral nutritional supplements. You say that this is your only food. The Plan denied your request. The Plan says oral supplements are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve oral nutritional supplements.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy but the documentation does not indicate that this therapy must be provided only on an intensive level in an inpatient rehabilitation facility. 

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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 laboratory services. 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 laboratory services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan.

You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because you were not aware that contrast increases your copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $275 copayment for CT scans. 

You have been asked to pay the allowed amount of $164.27, which is less than the $275 copayment for a CT scan. A CT scan falls 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 a CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that an expandable controller and electronic connection are covered as needed. 

We looked at the file and Medicare rules. The requested items are not needed, as the PWC's approved power options do not need to be controlled through a joystick. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve topical fluoride application (D1208), oral hygiene instructions (D1330), periodontal maintenance (D4910) and gingival irrigation (D4921).

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.

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 topical fluoride application (D1208), oral hygiene instructions (D1330), periodontal maintenance (D4910) and gingival irrigation (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity.

The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioimpedance Spectroscopy (93702).

You asked the Plan to pre-approve Bioimpedance Spectroscopy. You say that in your medical opinion the enrollee is at high risk of developing lymphedema and you believe the use of this device is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental for the detection of lymphedema and is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bioimpedance Spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve Bioimpedance Spectroscopy (93702).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for Skilled Nursing Facility services.

You asked the Plan to pay for the Skilled Nursing Facility. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim was submitted with an invalid (Health Insurance Prospective Payment System) HIPPS code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility have been met. Specifically, this claim was submitted with code JDID1. Per Medicare, this is a valid code. Therefore, we decided that the Plan has to pay for Skilled Nursing Facility services.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 1, 2020, to October 5, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services were not medically necessary. The Plan also says that the enrollee was under hospice care from October 1, 2020, to October 5, 2020, and Original Medicare covers hospice services.
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 skilled nursing services provided on October 1, 2020. 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. Medicare rules also say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 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 skilled nursing services provided on October 1, 2020 have not been met. The enrollee was also under the Medicare hospice benefit from October 2, 2020, to October 5, 2020. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 1, 2020, to October 5, 2020.