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

We decided that the Plan does not have to pre-approve Fluid Flow amniotic liquid allograft injections for the knees.

You asked the Plan to pre-approve the Fluid Flow injections. You say that you feel that the Plan should cover this to help your condition. The Plan denied your request. The Plan says this treatment is not currently considered safe/effective for your condition.

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 Fluid Flow injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral knee pain for which she is receiving physical therapy. She also takes Celebrex and cyclobenzaprine for pain. Fluid Flow injections have been requested to assist with pain management. This treatment is currently experimental/investigational. As such, it is not considered 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 Fluid Flow injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow amniotic liquid allograft injections for the knees.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee has a past medical history of diabetes, COPD, CAD and a stage 2 pressure ulcer and is living at home with weakness and balance problems. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), the topical application of fluoride varnish (D1206), the drugs or medicaments dispensed in the office for home use (D9630), the gingival irrigation - per quadrant (D4921), the periodontal scaling and root planing - four or more teeth per quadrant (D4341) and the unspecified periodontal procedure, by report (D4999).

You asked the Plan to pre-approve the dental services. You say that these are comprehensive services that the dental plan should cover. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), the topical application of fluoride varnish (D1206), the drugs or medicaments dispensed in the office for home use (D9630), the gingival irrigation - per quadrant (D4921), the periodontal scaling and root planing - four or more teeth per quadrant (D4341) and the unspecified periodontal procedure, by report (D4999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement hearing aid provided on February 3, 2021.

You asked the Plan to pay for the replacement hearing aid. You say that the replacement should be reimbursed due to the out-of-pocket cost. You say that the hearing aid is a necessity and $150 should be covered. The Plan denied your request. The Plan says hearing aids purchased from an out-of-network provider do not apply toward the warranty for replacements.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. Hearing aids replacements are only covered through warranty if they were purchased from a network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the replacement hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the replacement hearing aid provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a COVID-19 test (U0003) provided on August 31, 2020.

You asked the Plan to pay for a COVID-19 test. You say that this should be covered. The Plan denied your request. The Plan says this must be billed by the SNF.

The Plan must follow Medicare rules. Medicare rules say that "Part A" consolidated billing requires that a SNF must include on its Part A bill almost all of the services that a resident receives during the course of a Medicare-covered stay. 

We looked at the file and Medicare rules. The record shows that the enrollee was in a covered SNF stay when the service at issue was received. This service is subject to consolidated billing and must be billed by the SNF. Based on this information, we decided that Medicare rules for coverage of a COVID-19 test have not been met. Therefore, we decided that the Plan does not have to pay for a COVID-19 test (U0003) provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ski pass purchased March 25, 2020.

You asked the Plan to pay for the ski pass. You say that skiing motivates you to get outside and exercise and you would like to be able to use your wellness benefit towards the cost. The Plan denied your request. The Plan says ski passes are not covered under your benefits.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The Plan's rules for coverage of gym benefits have not been met because the ski pass purchased is not an eligible health and wellness benefit. Therefore, we decided that the Plan does not have to pay for the ski pass purchased March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and panoramic x-ray provided on February 1, 2021.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis and panoramic x-ray. You say that there is no charge for exams, cleanings, x-rays and fluoride for both in-network and out-of-network providers. You say that you believed there would be full coverage and the charges should be reviewed. The Plan denied your request. The Plan says your out-of-network liability is correct.

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, you are responsible for the difference between what the Plan pays and the billed amount for services received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and panoramic x-ray provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided March 26, 2021.

You asked the Plan to pay for the orthosis. You say that please review this claim due to the current COVID-19 pandemic guidelines and reconsider accordingly. The Plan denied your request. The Plan says there is evidence of misrepresented services.

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 proof of delivery and there was no signed delivery ticket. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (43281-AS) provided on December 1, 2020.

You asked the Plan to pay for surgical assistant services. You say that this service is supported in the records. The Plan denied your request. The Plan says the rendering provider is not eligible for coverage of surgical assistant services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a laparoscopy (43281-AS) provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Glucerna shakes.

You asked the Plan to pre-approve Glucerna shakes. You say that you have lost 30 pounds and that the requested nutritional supplement is medically necessary. The Plan denied your request. The Plan says nutritional supplementation is not a covered benefit.

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 Glucerna shakes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for infusion therapy services provided from October 7, 2020, to October 31, 2020.

You asked the Plan to waive the copayments for infusion therapy services (96374). You say that you cannot believe outpatient treatment is more expensive than inpatient treatment, so you believe the wrong code was used. The Plan denied your request. The Plan says the enrollee was charged the correct copayments.

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 the enrollee must pay a $325 copayment for Hospital Outpatient Facilities, other services.

You have been asked to pay a $213.73 copayment for the infusion therapy services (96374). The infusion therapy services (96374) fall within the Hospital Outpatient Facilities, other services benefit category. The copayment is less because the Medicare allowable amount for the service is less. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for infusion services provided from October 7, 2020, to October 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CTA's provided on September 14, 2020.

You asked the Plan to pay for the CTA's. You say that you attached the medical records, test results and Waiver of Liability for review. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 enrollee 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 CTA's provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and appliances.

You asked the Plan to provide a pneumatic compression device (E0676) and appliances. You say that you are having surgery and need the device to prevent blood clots. The Plan denied your request. The Plan says the device is considered a preventative service not covered by Medicare or the Plan.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and appliances.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 87798) provided to the enrollee on December 14, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 87798 (13 Units) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 87798 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (CPT 87798) provided to the enrollee on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam image capture (D0364) provided on March 22, 2021.

You asked the Plan to pay for the evaluation and imaging service. You say that these services were necessary, and you do not understand how you could have exceeded your benefit when you only saw each dentist once. The Plan denied your request. The Plan says a cone beam image capture is not covered by your dental benefit. Also, the Plan can only cover one limited oral evaluation per year. You previously had this type of exam on March 19, 2021, which was covered by the Plan. Therefore, your benefit for this service was exhausted on the date in question, and payment cannot be made.

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 or are requested in a frequency that is not covered by this benefit. Documentation shows that the Plan has already paid for one limited oral evaluation for you in 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam image capture (D0364) provided on March 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond July 27,
2021.

You asked the Plan to pre-approve the continued inpatient care. You say that it is felt that the enrollee needs
additional time in the inpatient setting. The Plan denied your request. The Plan says the enrollee's needs can be
met in a less restrictive setting.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 continued inpatient care. Our
reviewer says that the requested continuation of inpatient psychiatric care is not shown to be medically
necessary. Our physician reviewer found this 58-year-old female was admitted to the acute inpatient psychiatric
hospitalization on July 20, 2021 with Major Depressive Disorder, Recurrent, Severe without Psychotic
Features. Based upon review the records provided it was not expected this enrollee would improve in a
reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and
denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any
acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided
at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not
have dangerousness to herself or others but was compliant with her treatment. The health plan's denial of
continued inpatient psychiatric services is appropriate.

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 continued inpatient care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued inpatient psychiatric care beyond July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) provided October 30, 2020.

You asked the Plan to pay for the orthosis. You say that say the records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the billed supply code cannot be verified.

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 proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the delivery ticket did not include the carriers tracking number. The proof of deliver is not itemized to indicate the specific supplies and did not include an order number or details to corroborate the delivery ticket. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) provided October 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says you are no longer a threat to yourself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We looked at this physician's review, the file, and Medicare rules. In this case, there are insufficient medical records provided to show that the coverage criteria have been met for the requested services. The file shows that the Plan requested additional records, however, none were provided.

Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 29, 2020 by an
out-of-network (OON) provider.

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.

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 the physician services provided on December 29,
2020 by an out-of-network (OON) provider.