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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond May 13, 2020.You asked the Plan to pre-approve the continued SNF care. You say that the enrollee requires continued skilled care.The Plan denied your request. The Plan says daily skilled services are no longer necessary. The enrollee's needs can be met with custodial care and less than daily skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 95 year old female who was seen in the hospital after a fall. She was discharged back to the SNF for skilled care. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at a moderate to maximal assist level with functional mobility including gait to 10 feet. She required varying assist with ADLs.There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. Skilled nursing services are not needed on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continued SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond May 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehearing aids out of network.You asked the Plan to pre-approvehearing aids out of network. You say that you need new hearing aids and prefer the requested provider.The Plan denied your request. The Plan says Code of Regulations, Binaural(both ears) hearing aids may be needed  for: members over 18 years of age,tests of each ear reveal a hearing loss level of 35 dB or greater,, 1969 for 500, 1,000, and 2,000 Hertz (Hz) by pure tone air conduction. In addition,: Hearing Aids criteria,the plan covers the replacement of old hearing aids that no longer meet the needs of the recipient when the following is present: Past and present audiometric (used to measure hearing)reports used for fitting old aid and newaid, documentation that the old aid is performing properly but isno longer adequate, and documentation that hearing improved with the new aid. Based on our review of your records, we see that you meet theabove mentioned criteria. However, according to your 2020 plan Handbook, upon enrolling, you agreed to get carefrom in-network(contracted)providers. The recordsshow that the provider is not acontracted provider.. The requested servicesare available in-network. Therefore, you have been approved for hearing aids. The authorization number is 002240178. The authorization is valid from March 5, 2020 through June 5, 2020. You may reach the office to coordinate these services. Please continueto followup with your Primary CarePhysician (PCP), for any health care concerns that you may have.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.The Plan pays for hearing aids only. 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 hearing aids out of network. Our reviewer says that our physician reviewer found We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids out of network have not been met.Therefore, we decided that the Plan does not have to pre-approvehearing aids out of network.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (code D2954 x2).
You asked the Plan to pre-approve the posts and cores. You say that you cannot afford to pay for the root canals on your own. The Plan denied your request. The Plan says prefabricated post and core is not listed as a covered dental benefit in the dental benefit grid.
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 a prefabricated post and core in addition to crown (code D2954 x2).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural injection (64479).
You asked the Plan to pre-approve the epidural injection. You say that the epidural injection is medically necessary. The Plan denied your request. The Plan says that the member has not tried and failed 6 weeks of conservative therapy.
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 the epidural injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member has failed conservative therapy including NSAIDs, PT, muscle relaxants and hydrocodone. The pathology is clearly demonstrated on the MRI. 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 epidural injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural injection (64479).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eye exam (92014, 92015, 92341) and eyeglasses (V2020, V2207, V2781, V2744).
You asked the Plan to pre-approve the eyewear and eye exams. You say that the services are medically necessary. The Plan denied your request. The Plan says the benefits for eyewear and eye exams have been exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyeglasses up to $300 once every 2 years, and eye exams once a year. We looked at the file and the Plan's rules. The enrollee received eyeglasses and an eye exam already in November, 2019. The benefit has been exhausted at this time. Based on this information, we decided that the Plan's rules for coverage of the eyewear and eye exams have not been met. Therefore, we decided that the Plan does not have to pre-approve an eye exam (92014, 92015, 92341) and eyeglasses (V2020, V2207, V2781, V2744).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on January
13, 2020.
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 85060 is blood smear, peripheral, interpretation by
physician with written report.
We find that CPT code 85060 is not supported in the medical record. Specifically, code 85060 has a
Professional Component (PC)/Technical Component (TC) indicator of 8. The documentation shows that the
enrollee received outpatient services under an UB04 claim with bill type 137 (outpatient laboratory services)
and provider billed in a place of service of 22. Based on this information, we decided that Medicare rules for
coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not have to
pay for the blood smear services coded 85060 provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has an unstageable sacral pressure ulcer, debility, and dementia. The records do not support that his condition requires positioning of the body in ways not feasible in an ordinary bed. He does not need frequent or immediate changes in body position or special attachments that cannot be fixed and used on an ordinary bed. The enrollee does not meet the criteria for coverage and the semi-electric hospital bed is 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that the insertion of an interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says the utilization of the requested device is considered investigational.
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 requested services. Our physician reviewer found that the requested device remains experimental. More research is needed to show its safety and efficacy. Therefore, the requested services are not medically reasonable and necessary for this enrollee. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided to the enrollee on April 4, 2019.
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 that the claim was billed with a missing additional modifier or the diagnosis code is invalid.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan has not clarified clearly enough what needs to be corrected on the claim for the claim to be paid. It is not clear if the modifier or diagnosis code need to be adjusted. Therefore, we decided that the Plan has to pay for ambulance services provided to the enrollee on April 4, 2019.
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-approvea Myomomyoelectric orthosis for the enrollee.You asked the Plan to pre-approvethese services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that there is insufficient evidence in the literature that the myoelectric orthoses will improve the hemiparetic arm function or increase the member's participation in bimanual activities.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that a Myomo myoelectric orthosis is not considered medically reasonable and necessary in this case. The MyoPro Orthosis is not the most appropriate available supply or level of service for the patient in question considering potential benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis willimprove the long term outcomes for this patient, improve her hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase her participation in bimanual activities. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a Myomo myoelectric orthosis.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-approvea Myomo myoelectric orthosis for the enrollee
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the three ambulance transports provided on June 24, 2019 and June 27, 2019.You asked the Plan to waive the copayment for the three ambulance transports. You say that you were not informed there would be a copayment for these services.The Plan denied your request. The Plan says that that the copayments applied correctly.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan confirmed that you had already met your out-of-pocket maximum and did not owe a copayment for an earlier ambulance transport provided on June 24, 2019. The Plan then denied waiving the copayment for the three ambulance transports at issue in this appeal. The Plan has not submitted documentation to confirm that you had yet to reach the out-of-pocket maximum and would be liable for these copayments or how you reached the out-of-pocket maximum for an earlier transport but not the later transports.Therefore, we decided that the Plan has to waive the copayment for the three ambulance transports provided on June 24, 2019 and June 27, 2019.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 waive the coinsurance forthe walker provided on February 19, 2020.You asked the Plan to waive the coinsurance forthe walker. You say that you were told there would be no charge.The Plan denied your request. The Plan says that coinsurance was applied correctly.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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a 20% coinsurance for the walker. The walker falls within the durable medical equipment and related supplies benefit category. 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 coinsurance forthe walker provided on February 19, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve excision of neurofibroma (64788).You asked the Plan to pre-approve excision of neurofibroma (64788). You say that the requested excision of neurofibroma is medically necessary.The Plan denied your request. The Plan says that the requested excision of neurofibroma is 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 excision of neurofibroma (64788). Our reviewer says that the requested excision of neurofibroma is medically necessary. Our physician reviewer found the enrollee has requested removal of a neurofibroma of the lower back that was symptomatic. Plastic Surgery documentation from 10/8/19 notes that the enrollee had undergone previous neurofibroma excision. He complains of a neurofibroma ofthe lower back, which he reports is itchy and hurts. Examination notes a 1.2 cm neurofibroma of the lower back. Plan was for resection. The enrollee is with a symptomatic neurofibroma of the back. It is itchy and painful. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. As the enrollee has functional impairment (pruritis and tenderness) related to his back neurofibroma, resection of this lesion satisfies Medicare medically necessary criteria. The requested procedure is medically reasonable and necessary for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision of neurofibroma (64788) have been met.Therefore, we decided that the Plan has to pre-approve excision of neurofibroma (64788). 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 disposable sensor represented by CPT code A9276.You asked the Plan to pre-approve the disposable sensor used with a Guardian CGM. You say that the type of CGM you use is most appropriate and that the sensors being requested are medically necessary.The Plan denied your request. The Plan says the Guardian Continuous Glucose Monitor does not meet Medicare's definition of a therapeutic CGM and that the requested sensors are non-covered.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The records show that the sensors you are requesting coverage for are used with a CGM that is considered non-therapeutic. Medicare only covers CGMs and supplies that are for use with a CGM that meets the definition of therapeutic.Therefore, we decided that the Plan does not have to pre-approve a disposable sensor represented by CPT code A9276.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided by a participating provider on January 27, 2020.
You asked the Plan to waive the copayment for an ECG. You say that you have never been charged a copayment for this before. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $10 copayment for outpatient diagnostic tests/non-radiological diagnostic tests. You have been asked to pay a $10 copayment for an ECG. When additional services are provided during an office visit, additional copayments are applied; therefore, the correct copayment has been applied. An ECG falls within the outpatient diagnostic tests/non-radiological diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ECG provided by a participating provider on January 27, 2020.