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

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 17, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you believe this service should be covered because there was no transport. The Plan denied your request. The Plan says this service is not covered by Medicare.
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 on March 17, 2021. 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 response and treatment with no transport (A0998) provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower with handrails.
You asked the Plan to pre-approve a walk-in shower with handrails. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower with handrails.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan provided on May 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a CT scan. You say that the rendering physician is a hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtained prior authorization. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that these services were not urgent or emergent.
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 a CT scan provided on May 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on January 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician The Plan says that the referring provider is also 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 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 pain management services provided on January 15, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM) (CPT code K0553) provided to the enrollee on April 1, 2021.
You asked the Plan to pay for the supplies. 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Documentation submitted did not sufficiently document the member's medical condition to support the medical necessity for the billed supply code; nor did documentation indicate the provider ordered the billed supply code. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM) (CPT code K0553) provided to the enrollee on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 (CPT code 81479) provided to the enrollee on September 25, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the submitted documentation shows that the enrollee has lung cancer with multiple primary tumors. The Plan states Medicare requires documentation for the requested genetic test Guardant360 show that the tissue based CGP (genomic or tumor profiling) is infeasible (quantity not sufficient for tissue based CGP or invasive biopsy is medically contraindicated or specifically in non-small cell lung cancer (NSCLC) has shown no actionable mutations. The Plan states as documentation does not indicate that tissue based CGP is infeasible or that an invasive biopsy is medically contraindicated or specifically in NSCLC has shown no actionable mutations, Medicare criteria are not met, and this request is denied.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The enrollee is not seeking treatment and is being monitored for any changes. Medicare criteria are not met as tissue was available for CPG testing and the enrollee is not seeking further cancer treatment at this time. Therefore, we decided that the Plan does not have to pay for Guardant360 (CPT code 81479) provided to the enrollee on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitoring system.
You asked the Plan to provide a therapeutic continuous glucose monitoring system. You say that the enrollee's doctor recommended a CGM because of pain when finger stick testing. The Plan denied your request. The Plan says there are no notes to show how often the enrollee tests, if the enrollee is taking 3 or more daily injections of insulin or if a treating provider has evaluated to see if a CGM system is medically needed.
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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, or has had an in-person visit with their treating physician to assesses adherence to their regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of facet joint injections (64495). 
 
You asked the Plan to pre-approve a third level of facet joint injections. You say that you need this to relieve 
your pain. The Plan denied your request. The Plan says a third level is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that that one to two levels of facet joint injections, 
either unilateral or bilateral, are allowed per session per spine region.  
 
We looked at the file and Medicare rules. The records do not document unique circumstances or reasoning for 
an exception to allow a third level in a session. Based on this information, we decided that Medicare rules for 
coverage of a third level of facet joint injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a third level of facet joint injections (64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on November 12, 2020.
You asked the Plan to pay for a bone replacement graft. You say that you told the provider not to do any work that was not covered. The Plan denied your request. The Plan says the service at issue is not a covered 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 pay for a bone replacement graft (D7953) provided on November 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee. 
 
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 requested procedure is not supported because research has not found it to be safe and 
helpful for treatment of pain. 
 
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 it has been seven years since the last radiofrequency ablation. The guidelines require the diagnostic 
work-up to be repeated. Furthermore, the utilization criteria limits RFA to two levels per sessions, and it cannot 
be pulsed or cooled. The request does not meet these criteria; therefore, the request is considered 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 radiofrequency ablation (RFA) for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT code 82306) provided to the enrollee on January 19, 2021.

You asked the Plan to pay for the laboratory testing. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service was not necessary.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The diagnoses of the enrollee do not meet the criteria for Medicare. The test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT code 82306) provided to the enrollee on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a P-C IOL.
You asked the Plan to pre-approve a P-C IOL. You say that the requested item is the lens that will best suit you and your vision needs. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve a P-C IOL.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on March 17, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were given an inhaler which you
were billed in full for. The Plan denied your request. The Plan says self-administered drugs are not covered
under Part B of Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided on March 17, 2021.
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

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 prescriber confirmed that you are not on insulin.

The Plan must follow Medicare rules. The rules say that a continuous glucose monitor is covered for patients who are insulin treated.

There is no evidence of insulin treatment. 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 continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
April 26, 2021, to April 27, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that it took 16 hours before you 
were provided with an actual bed, and instead you were laying on a gurney in the emergency room. You feel 
you should not have to pay for these services. The Plan denied your request. The Plan says covered services 
include but are not limited to semi-private rooms. While a semi-private room is covered by inpatient care costs, 
it is not the determining factor for whether you are inpatient status or not. You were admitted as an inpatient on 
the dates in question, and therefore the inpatient copayment applies. 
 
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 $225 
copayment for each of the first 7 days of an inpatient hospital stay. You have been asked to pay a $225 copayment for the inpatient care. 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 inpatient hospital care provided from April 26, 2021, to April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full cast retainer crown (D6791), pontic (D6211), and porcelain fused retainer crown (D6751) provided on March 9, 2021.

You asked the Plan to pay for the retainer crowns and pontic. You say that you have not been able to see a written copy of the summary of benefits. You also say that you have not been able to see in writing or hear verbally the exclusions and limitation that are the basis of this denial. 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. The contract does not state that the initial placement of bridges or dentures is covered by the Plan. Therefore, we decided that the Plan does not have to pay for the full cast retainer crown (D6791), pontic (D6211), and porcelain fused retainer crown (D6751) provided on March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation SNF services provided from
December 20, 2020, through January 18, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says continuation of SNF services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. He had uncomplicated wound care to his right above the knee amputation. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee required varying assist with transfers and activities of daily living from stand by assist to dependence. The enrollee tolerated a regular diet and thin liquids. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from December 20, 2020, through January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and 
electronic connection. 
 
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 with harness upgrade 
and electronic connection are approved to control three or more power features. 
 
We looked at the file and Medicare rules. The file shows that the requested items are not needed to control the 
approved power options. 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 upgrade and electronic connection.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 your medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of low back pain, lumbar raidculopathy, post-laminectomy syndrome, sacroilitis, cervicalgia, and cervical radiculopathy. She had bilateral SI joint injections on May 7, 2021 and June 4, 2021 with 75 percent pain relief. The use of RFA on SI joint mediated pain is considered experimental/investigational in nature. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.