Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The
Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee is currently
undergoing treatment at an acute care hospital (ACH) for pneumonia and influenza in the setting of end-stage
pulmonary disease. The enrollee is receiving antibiotics, antivirals, nebulizers, steroids, oxygen and BiPAP.
The enrollee is not intubated/ventilated. 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.
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 long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Go-Go Elite Traveller Plus 3 wheel electric scooter.You asked the Plan to pre-approvea scooter (K0806). You say that because of your spinal injury history you need a scooterto complete your MRADLs.The Plan denied your request. The Plan says you may qualify for a power wheelchair but this scooter hasadded capabilities not needed for use in the home and therefore not covered by Medicare.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. Group 2 power operated vehicles K0806 are statutorily not covered.Therefore, we decided that the Plan does not have to pre-approvea Go-Go Elite Traveller Plus 3 wheel electric scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99202) provided by "the provider" on September 20, 2019.You asked the Plan to pay forthe office visit. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this service is not a covered benefit under your health plan policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit (99202) provided by "the provider" on September20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency transportation (A0429) and ground mileage (A0425) provided June 16, 2019.You asked the Plan to pay forthe ambulance services. You say that that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says this date of service is after the enrollee's date of death.The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. The records show that this enrollee's date of death is June 12, 2019.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not haveto pay forthe BLS emergency transportation (A0429) and ground mileage (A0425) provided June 16, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit provided on August 29, 2019.
You asked the Plan to pay for the emergency room visit. You say that the claim was not paid in full or under
the terms of the contract for the services provided to the member. The Plan denied your request. The Plan says
Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the
member's terminal illness and Medicare is responsible for payment until the start of the next month after
revocation.
Medicare rules 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.
The member was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record
shows the patient was enrolled in hospice from July 25, 2019 to August 24, 2019. However, Medicare is still
responsible for payment until the start of the next month after revocation. Therefore, we decided that the Plan
does not have to pay for the emergency room visit provided on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple extractions (41899).You asked the Plan to pre-approve the dental services. You say that you need a total hip replacement. You say that you cannot have this surgery until you have had your teeth extracted.The Plan denied your request. The Plan says extractions are 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, extractions are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvemultiple extractions (41899).
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 the plan should reprocess the claims for
payment. 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 on August 29, 2019. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (SPECT).
You asked the Plan to pre-approve the myocardial perfusion imaging. You say that the enrollee is not able to walk and has a device on his foot, which prevents him from being able to get on the treadmill. You say that the enrollee is a career pilot and has a cardiac history in addition to being overweight and having cardio myopathy. You say that the enrollee is a high-risk patient and that the test needs to be performed. The Plan denied your request. The Plan says the clinical information does not support that the criteria for coverage have been met.
The Plan must follow Medicare rules. Medicare rules say that cardiovascular stress testing is not covered when being done as part of an occupational fitness evaluation. We looked at the file and Medicare rules. The records show that the testing has been ordered because the enrollee is an airplane pilot and this test is FAA required. This means that the testing is being done for occupational purposes. Based on this information, we decided that Medicare rules for coverage of the myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (SPECT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4
quadrants.
You asked the Plan to pre-approve the dental services. You say that you need the deep cleaning in order to get
dentures. The Plan denied your request. The Plan says periodontal scaling and root planing 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, periodontal scaling and root plaing is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet join injections.
You asked the Plan to pre-approve the facet join injections. You say that the records provided support the need for the requested injections. The Plan denied your request. The Plan says that there is no clinical information documenting medical necessity.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for certain indications. 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 facet join injections. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has chronic low back pain and has failed multiple conservative therapies. The enrollee received laminectomy services at L3-L4 for spinal stenosis. The enrollee has L5-S1 facet arthropathy on MRI. The enrollee's pain pattern is hip and thigh above the knee. The enrollee's facet arthropathy is documented clearly on MRI and he does not have radicular symptoms. The referral patter of L5-S1 facet fits the enrollee's complaints and the requested injections are medically reasonable and 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 facet join injections have been met. Therefore, we decided that the Plan has to pre-approve facet join injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.You asked the Plan to pre-approvetheseservices. You say that you have a family history of cancer.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that BRCA testing is not covered for screening.We looked at thefile and Medicare rules. The file shows that you do not have a personal history of a cancer for which BRCA testing is covered. 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-approveBRCA genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need the chair in order to shower since you
will not be able to stand after your scheduled knee surgery. The Plan denied your request. The Plan says this
item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit provided on June 8, 2019.You asked the Plan to pay for the emergency room visit. You say that the claim was not paid in full or under the terms of the contract for the services provided to the member. The Plan denied your request. The Plan says Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the member's terminal illness.Medicare rules 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. The member was under the Medicare hospice benefit forthe dates of service at issue in this appeal. The record shows proof of hospice election from June 8, 2019 to June 12, 2019. Therefore, we decided that the Plan does not have to pay forthe emergency room visit provided on June 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies codes as A4253, A4259, A4256 and A4235 provided August 2, 2019 to October 21, 2019.
You asked the Plan to pay for the diabetic supplies. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted. The proof of delivery also is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified Therefore, we decided that the Plan does not have to pay for diabetic supplies codes as A4253, A4259, A4256 and A4235 provided August 2, 2019 to October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), and prophylaxis (D1110) provided onSeptember 6, 2019.You asked the Plan to pay forthe dental services. You say that you were not aware that the provider was out of network.The Plan denied your request. The Plan says authorization was required for the services. The Plan also says the services can be provided in network.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 services are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), and prophylaxis (D1110) provided on September 6, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermediate repair of wound, ECG report, and ED visit
provided on July 10, 2019.
You asked the Plan to pay for the intermediate repair of wound, ECG report, and ED visit. You say that the
treating emergency physician provided medical care in an ED setting as mandated by the Emergency Medical
Treatment and Active Labor Act which requires the provider to evaluate and treat all patients presenting to the
ED, based on the "prudent layperson" standard. The Plan denied your request. The Plan says Original Medicare
would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's
terminal condition.
Medicare rules 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.
B. Waters was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we
decided that the Plan does not have to pay for the intermediate repair of wound, ECG report, and ED visit
provided on July 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formagnetic resonance imaging (an MRI) (72148) provided on June 19, 2019.You asked the Plan to waive the copayment foran MRI. You say that you are not sure why you are getting copay fees. You also say that this bill for $60 should be sent to the pain management doctor because he ordered this MRI and you already had an MRI on file.The Plan denied your request. The Plan says outpatient diagnostic tests have a $60 copayment. The Plan also says this service includes complex tests such as MRIs.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 $60 copayment for outpatient diagnostic tests. You have been asked to pay a $60 copayment for an MRI. This servicefalls within the outpatient diagnostic tests benefit category, which includesMRIs. 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 formagnetic resonance imaging (an MRI) (72148) provided on June 19, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shower chair.You asked the Plan to pay fora shower chair. You say that you believethe requested shower benchis medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay fora shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (CPT E0118).
You asked the Plan to pre-approve the knee scooter. You say that the enrollee needs to be non-weight bearing due to body with making the Achilles painful. The Plan denied your request. The Plan says there is no Medicare coverage available for the item being requested.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that requests for coverage of CPT E0118 will be denied as not medically reasonable and necessary. We looked at the file and Medicare rules. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (CPT E0118).