Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the office services provided on July 2, 2020.

You asked the Plan to reimburse for the office services. You say that you are requesting reimbursement of
services rendered. The Plan denied your request. The Plan says the Plan states they paid the Medicare
allowable rate of $231.58 via check on May 24, 2021, with a member responsibility of $0.04 coinsurance,
leaving $240.82 as upheld.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file shows that you paid up front for services from a non-contracted provider on July 2, 2020.
Unfortunately, this reimbursement is not the responsibility of the Plan. The Plan paid the Medicare allowed
amount (minus 4 cents, and that is all they have to do. The rules say that for services of a non-contracting,
original Medicare, participating provider; there is no balance billing paid by either the plan or the enrollee. 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 reimburse for the office services provided on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Icosapent Ethyl 1-gram capsule.

You asked the Plan to pre-approve Icosapent Ethyl. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Icosapent Ethyl 1-gram capsule.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151 x 9).
You asked the Plan to pre-approve these services. You say that these services are medically necessary for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 requested services are not medically necessary. Our physician reviewer found that the enrollee appears to have reached a plateau in function. Ongoing home health physical therapy services are not shown to be medically necessary or reasonable. 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 services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151 x 9).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics (L3020, L3216, L3310).

You asked the Plan to pre-approve foot orthotics. You say that you require the custom foot ware to prevent future falls. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3020, L3216, L3310).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the semi-electric hospital bed is necessary for the enrollee. The Plan denied your request. The Plan says that there was insufficient medical documentation.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our 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 semi-electric hospital bed. Our reviewer says that the service is reasonable and necessary. Our reviewer found last year the hospital bed was approved as the enrollee needed frequent changes in body position that were not feasible in an ordinary bed. This documentation was included in the case file. The continued rental of the semi-electric hospital bed has been shown to be reasonable and necessary service for the enrollee. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the semi-electric hospital bed have been met. Therefore, we decided that the Plan has to pre-approve a semi-electric hospital bed.
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 a grab bar for bathtub or toilet (E0246, E0243).

You asked the Plan to pre-approve a grab bar. You say that you need these items to prevent falls. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar 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 grab bar for bathtub or toilet (E0246, E0243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on March 24, 2021.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
A review of the file does not show that the remote encounter was insufficient to document objective joint
laxity. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve
(L1833, L2397) provided to the enrollee on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 inpatient hospital services. Our
reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The
enrollee is undergoing a planned elective total shoulder arthroplasty.

The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure.
The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The
procedure is currently approved as an ambulatory procedure. There is no documentation provided to support
the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the
enrollee does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acrylic socket (L5631), alignable system (L5920) and knee extension assist (L5850). You asked the Plan to pre-approve the acrylic socket, alignable system and knee extension assist. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says this additional equipment does not meet criteria for coverage.
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 acrylic socket, alignable system and knee extension assist. Our reviewer says that per the manufacturer's website, CPT code L5850 is not included as part of the requested knee prosthesis. Our physician reviewer found this equipment exceeds the member's needs. In addition, Medicare rules say that when an above knee preparatory (L5590) prosthesis is provided, CPT code L5952 will be denied as not medically reasonable and necessary. The acrylic socket cannot be used with the approved prosthesis. Also note, the requested alignable system is not appropriate for the approved prosthesis. The approved prosthesis is specifically non-alignable. 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 acrylic socket, alignable system and knee extension assist have not been met. Therefore, we decided that the Plan does not have to pre-approve the acrylic socket (L5631), alignable system (L5920) and knee extension assist (L5850).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance transportation (A0429, A0425)
provided on November 2, 2020.
You asked the Plan to pay for emergency ambulance transportation. You say that you want the Plan to pay for
these services. The Plan denied your request. The Plan says the claim was billed with an invalid zip code.
Medicare rules say that electronic billers are required to submit, in addition to the loaded ambulance trip's
origin information, the loaded ambulance trip's destination information. The Plan follows the same rules.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of emergency ambulance transportation have not been met. Specifically, the record does not show
that the ambulance's trip origin and destination zip codes were reported correctly on the submitted claim.
Therefore, we decided that the Plan does not have to pay for emergency ambulance transportation (A0429,
A0425) provided on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).

You asked the Plan to pre-approve an intermittent limb compression device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device (E0676).
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99205) to be provided by a
tertiary provider.
You asked the Plan to pre-approve the office visit. You say that you are requesting an office visit with an innetwork
tertiary provider. The Plan denied your request. The Plan says the requested services are not medically
necessary. 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 office visit. Our physician reviewer found you do not have a diagnosis
of cancer. Although the lesions are suspicious for cancer biopsies have not confirmed and you need to have
further work-up to confirm a diagnosis. Without a diagnosis of cancer referral to a tertiary
hematologist/oncologist would not be 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 the office visit have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found
no exception that would require the Plan to pre-approve the office visit. Therefore, we decided that the Plan
does not have to pre-approve the office visit (CPT code 99205) to be provided by a tertiary provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex-C (CPT code J1561), for the enrollee.

You asked the Plan to pre-approve the medication. You say that the enrollee has a positive history from receiving the treatment. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 medication. Our physician reviewer found first line treatment for flares is corticosteroids, which were not described as having been tried and failed for this flare-up prior to considering the IVIG (Gamunex-c). Therefore, this medication will be considered not 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Gamunex-C (CPT code J1561), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of a limited area.

You asked the Plan to pre-approve a PET scan of a limited area. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan of a limited area. Our reviewer says that the services are not medically necessary. Our physician reviewer found review of the records indeed shows a signed and verified report of a PET computed tomography (CT) scan dated July 16, 2021 and that report showed no technical reason why a repeat would be necessary at this time. The medical necessity for a repeat PET/CT scan following a signed PET/CT done on July 16, 2021 has not been established. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan of a limited area have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of a limited area.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that is not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided January 30, 2021, and February 09, 2021.

You asked the Plan to pay for [the ambulance response and treatment, no transport. You say that you thought you were saving the Plan money but not accepting the transport and did not realize you would have to pay the bill. The Plan denied your request. The Plan says this service is not covered since there was no transport.

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 January 30, 2021, and February 9, 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, no transport (A0998) provided January 30, 2021, and February 09, 2021.