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

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve the continued SNF care. You say that The Plan denied your request. The
Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 11, 2020
to April 19, 2020. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pre-approve continued SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from October 8, 2019 through October 17, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.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 services have not been met. A search on the Data.Medicare.gov in Hospital General Information web sites with the facility name is not find an active listing for the provider. Per the above guidelines we find the Medicare rule for payment of this October 08, 2019 through October 17, 2019, claim has not been met.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee from October 8, 2019 through October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet nerve neurolysis.You asked the Plan to pre-approve the services. You say that this has been done in the past, and it has helped.The Plan denied your request. The Plan says this is 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are status post cervical fusion after the prior service did not "work well." Therefore, the request to repeat the service is 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-approverepe at facet nerve neurolysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the outpatient hospital observation services (G0378) provided February 17, 2020 to February 19, 2020.You asked the Plan to waive the copaymentfor this service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Thecontract with the Plan clearly says that the enrolleemust pay a $200 copayment for outpatient hospital observation services. The enrolleehas beenasked to pay a $200 copayment for outpatient hospital observation servicesprovided. This means that she hasbeen asked to pay the correct amount based on hercontract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copaymentfor the outpatient hospital observation services (G0378) provided February 17, 2020 to February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and therapeutic activities provided by a chiropractor from January 6, 2020 to January 25, 2020.
You asked the Plan to pay for office visit and therapeutic services. You say that you were told that you would have to pay $15 for each visit and that your treatments would be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered when performed by a chiropractor.
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 services at issue were not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit and therapeutic activities provided by a chiropractor from January 6, 2020 to January 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you need a power seat elevation feature to transfer safely and reach things. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
The Plan follows Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. A power seat elevation feature does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips (A0120).You asked the Plan to pre-approveadditional routine transportation trips. You say that the requested additional transportation is necessary for you to be able to get to your medical appointments.The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and panoramic
x-ray provided on May 2, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that
you do not have dental care, but these services were medically necessary and should be covered by your
medical plan. The Plan denied your request. The Plan says these services are not covered by your medical plan.
The Plan also says that multiple requests were made to obtain a corrected claim, but the information was not
received.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral
evaluation and panoramic x-ray provided on May 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Guardian transmitter and sensor.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says a product is being requested that is not FDA-approved as a therapeutic monitor.The Plan must follow Medicare rules. Medicare rules say that CGMs are only covered when they are considered therapeutic.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 the Guardian glucose monitor transmitter and sensor is not considered therapeutic. It is not intended to be used directly for making therapy adjustments, but rather to provide an indication of when a finger stick may be 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Guardian transmitter and sensor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that you need massage therapy to treat your lymphedema. The Plan denied your request. The Plan says massage therapy is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the U-step walker (E0147) with a laser light (E1399).
You asked the Plan to pre-approve the U-step walker with a laser light. You say that the U-step walker comes with the laser and will help reduce the enrollee's frequent episodes of freezing gait and reduce his risk for falls. The Plan denied your request. The Plan says your current walker already in the home is considered duplicate equipment and the laser light is considered a convenience item and is not covered.
The Plan covers all items that Medicare covers. Medicare rules state that laser lights are not covered because they are not primarily medical in nature. The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a standard walker. The standard walker serves the same purpose as the u-step walker. Therefore, we decided that the Plan does not have to pre-approve the U-step walker (E0147) with a laser light (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 29.
You asked the Plan to pre-approve the core build up. You say that the enrollee would benefit from a crown for tooth # 29 in order to prevent further fractures. The Plan denied your request. The Plan says core build up 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, the core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 29.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on January 3, 2020.You asked the Plan to waive the copayment foran X-ray. You say that you disagree with the charges if they are for the reading of an X-ray.The Plan denied your request. The Plan says the claims were processed correctly,and the enrollee is being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for each basic imaging service. The enrollee has been asked to pay the allowed amount of $35.61, which is less than the $40 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foranX-ray provided on January 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an MRI. You say that you would like the member to have an MRI at a specific location.The Plan denied your request. The Plan says there are in-network providers available for these services.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 requested provider in this case is not a network provider with the Plan. 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 these items/services.Therefore, we decided that the Plan does not have to pre-approve an MRI to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that because of your medical condition you have to wear the stockings for the leg pain. The Plan denied your request. The Plan says compression stockings are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve knee surgery.
You asked the Plan to pre-approve knee surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 knee surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you present with persistent left medial knee pain following a hyperextension event. You report severe pain that disrupts sleep and limits activities of daily living. Clinical exam findings have documented positive McMurray's test and medial joint line tenderness consistent with imaging evidence of a complex medial meniscus tear and reported radiographic evidence of mild to moderate osteoarthritic changes of the medial joint line. You have failed reasonable and/or comprehensive conservative treatment, including activity modification, medications, and physical therapy. Under consideration is a request for left knee surgery, including chondroplasty/microfracture and medial meniscectomy. Given your severe pain and functional limitations, findings of complex medial meniscus tear and osteoarthritis, and failure of conservative treatment, this request is supported by current evidence based medical literature as discussed above. You have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for knee surgery, and the requested surgery would be considered the standard of care. Therefore, this request for left knee surgery (CPT codes 29877, 29879, and 29881) is 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 knee surgery have been met. Therefore, we decided that the Plan has to pre-approve knee surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tandem Tslim X2 insulin pump.You asked the Plan to pre-approve a replacement insulin pump. You say that you need a new insulin pump.The Plan denied your request. The Plan says there is no documentation that the current pump is not working correctly or medical necessity to replace the current insulin pump.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that your Medtronic pumpis less than five years old,still under reasonable useful lifetime, and there is no indication it does not work.Therefore, we decided that the Plan does not have to pre-approve a Tandem Tslim X2 insulin pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
You asked the Plan to pre-approve a portable oxygen concentrator. The Plan denied your request. The Plan says that the enrollee can perform activities with a regular stationary oxygen concentrator for home use, and/or portable oxygen tanks to be used when moving around.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a stationary oxygen concentrator and portable tanks. A stationary oxygen concentrator and portable tanks serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on April 28, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99223 is 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. In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient care, typically 70 minutes per day. We find that CPT code 99223 is not supported in the medical record. Specifically, there is no documentation of initial hospital care for the date of service at issue. The records show that the enrollee was not admitted to the hospital until April 29, 2019. 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 pay for the initial hospital care rendered on April 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided thatthe Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRFcare. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee'snursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee'scurrent medical status does not require intensive physician or nursing oversight in an IRF. The enrolleemay benefit from additional multiple therapies; however,the enrollee'sfunctional level with fatigue and decreased endurancedo not require or indicate that this therapy must be provided withan intensive level programat an inpatient rehabilitation facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full night titration study for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your
request. The Plan says there must be evidence of lung failure, heart faulure, seizures, or other health problems.
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 study. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has obstructive sleep apnea, with AHI of 64.9 obtained on a home sleep study. However, the
enrollee did not have prolonged or severe hypoxemia, and does not have significant lung disease, heart failure,
neuromuscular disease, or other conditions that would interfere with an auto-titrating CPAP (APAP) trial.
Therefore an attended PAP titration study is not medically necessary. Such a study could become necessary if
APAP is unsuccessful in correcting the sleep disordered breathing.
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 study have not been met. Therefore, we decided that the Plan does not have
to pre-approve a full night titration study for the enrollee.