Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable gaseous oxygen system (E0431) provided on December 9, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the portable gaseous oxygen system. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these OON 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 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 portable gaseous oxygen system (E0431) provided on December 9, 2020, by an out of network (OON) provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met.

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 was admitted for surgical
treatment of a meningioma Medical problems 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. There is no documented need for intensive
rehabilitation services. There is not a reasonable expectation that this patient 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed (E0255) and trapeze bar attached to bed (E0910) provided June 5, 2020.

You asked the Plan to pay for the hospital bed and trapeze bar. You say that the enrollee is diagnosed with COPD and you provided the hospital bed and trapeze to the enrollee. The billed items should be covered under the plan. You attached the medical records to prove the medical necessity. The Plan denied your request. The Plan says the requested items are not medically necessary as the enrollee does not require positioning of the body in ways not feasible with a fixed height hospital bed.

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 pay for the hospital bed and trapeze bar. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The medical progress reports do not support a need for a semi-electric hospital bed, abdominal pain or why a trapeze is needed for medical reasons. The request for a semi-electric hospital bed is not medically 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 hospital bed and trapeze bar have not been met. Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed (E0255) and trapeze bar attached to bed (E0910).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 units of physical therapy services (97110) and home visit (99347) provided on October 29, 2020.
You asked the Plan to pay for 4 units of physical therapy and a home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that home service codes cannot be billed by a physician unless the physician was present in the beneficiary's home. We find that CPT code 99347 and 97110 is not supported in the record. Specifically, the documentation does not support that 2 hours of physical therapy services were rendered. Additionally, the home visit was provided by a licensed vocational nurse. There is no indication that the physician was present in the beneficiary's home for this service. Based on this information, we decided that Medicare rules for coverage of the physical therapy and home visit have not been met. Therefore, we decided that the Plan does not have to pay for the 4 units of physical therapy services (97110) and home visit (99347) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider.

You asked the Plan to waive the copayment for an office visit. You say that the correct copayment has been applied. 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 $40 copayment for physician/practitioner services.

You have been asked to pay a $40 copayment for an office visit. An office visit falls within the physician/practitioner services 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 office visit provided by a participating provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that your provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and OON providers from the enrollee's insurance The Plan denied your request. The Plan says these services were rendered by an OON provider, and prior authorization was not obtained. The Plan also says that the enrollee was referred by another non-participating provider.

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 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 domiciliary or rest home visit provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the PCD (E0652).

You asked the Plan to pre-approve the PCD. You say that you would like reconsideration because the PCD is medically necessary. The Plan denied your request. The Plan says that the member was in a Skilled Nursing Facility at the time of the appeal review.

The Plan follows Medicare rules. Medicare rules say that A PCD coded as E0652 is covered when the beneficiary has lymphedema extending onto the chest, trunk and/or abdomen, the coverage criteria for E0650 or E0651 are met and when the beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial.

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 PCD. Our reviewer says that the documentation meets coverage criteria and supports the medical necessity of the device in question. Our physician reviewer found there is satisfactory documentation of severe long-standing lymphedema along with satisfactory documentation of lower extremity and truncal involvement as well as failure of more basic lymphedema devices. The member's body habitus, age, and comorbidities would make a standard compression regimen untenable.

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 PCD have been met. Therefore, we decided that the Plan has to pre-approve the PCD (E0652).

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 reimburse you for the foot orthotic purchased on September 22, 2020.
You asked the Plan to reimburse you for the foot orthotic (L3010). You say that the orthotic relieves stress and pain when walking. 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 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 reimburse you for the foot orthotic purchased on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary/prostate panel (87640 87653 87512 87482 87900 and 87799).

You asked the Plan to pay for the urinary/prostate panel. You say that you would like reconsideration because this service provides accurate, sensitive and quantitative evaluation of patient infections. The Plan denied your request. The Plan says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the urinary/prostate panel, was requested solely for screening purposes.

Medicare does not cover this test solely for screening purposes. Please note, the documentation submitted does not include medical records to verify why this testing was ordered or if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the urinary/prostate panel (87640 87653 87512 87482 87900 and 87799).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy provided by an out-of-network provider.

You asked the Plan to pay for the punch biopsy of skin (11104). You say that the procedure was medically
necessary. The Plan denied your request. The Plan says you did not request prior authorization for the nonemergent
procedure.

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 services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that
the Plan does not have to pay for the biopsy provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from August 6, 2020, through August 25, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says with limited exceptions, members must use network providers to get medical care and services. The only exceptions are emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.
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 did not pre-approve the inpatient admission. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from August 6, 2020, through August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory services provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the root canal (D3320) provided on June 12, 2020.
You asked the Plan to reimburse you for the dental service. You say that the service should be covered. The Plan denied your request. The Plan says root canal 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the root canal (D3320) provided on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periapical radiographic images (D0230 x3).

You asked the Plan to pay for periapical radiographic images. You say that you did not give permission for the
provider to perform the additional three periapical radiographic images. The Plan denied your request. The Plan
says the benefit for this service was exhausted. The Plan provides coverage for one periapical radiographic
image per calendar year.

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. The Plan covers one periapical
radiographic image per calendar year.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of periapical radiographic images have not been met. Specifically, the benefit for the service at issue
was exhausted. Records show that you had four periapical radiographic images. The Plan provides coverage 
for one periapical radiographic image per calendar year. Therefore, we decided that the Plan does not have 
to pay for periapical radiographic images (D0230 x3).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve an extension of coverage beyond the 100-day benefit for skilled nursing facility (SNF)care.
You asked the Plan to pre-approve the continuation of SNF care. You say that soon after the enrollee started therapy at the SNF, she fell and broke her ankle and was deemed non-weight bearing. You say that about a week later the enrollee contracted COVID-19. You say that the enrollee was then placed in isolation and was unable to receive any physical therapy (PT) for over a month. You also say that the enrollee's physical condition deteriorated while she was in isolation and she needs the specialized services of the SNF, on a nearly daily basis, so that she can safely rehabilitate. The Plan denied your request. The Plan says that they cannot extend the enrollee's covered skilled care days beyond the covered 100-day limit. The Plan says that there has not been a gap in skilled care beyond 60 days. The Plan says a benefit period ends on the date the enrollee has not been an inpatient in a hospital or SNF, receiving a skilled level of care, for 60 consecutive days. The Plan also says that a new benefit period can begin only after any existing benefit period ends.
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. We find that the documentation provided shows that the enrollee was in SNF care from December 3, 2020, to January 27, 2021. The Plan has not substantiated that the enrollee has been receiving SNF care for 100 days. The Plan has not substantiated that the enrollee had not had a 60-day gap, where a new benefit period would begin. We requested documentation to substantiate the specific dates that the enrollee received SNF care, but no documentation was provided. Without the exact dates of service, we cannot confirm that the 100-day limit had been exceeded, nor that there was not a gap in benefits of 60 days for SNF services. Therefore, we decided that the Plan has to pre-approve an extension of coverage beyond the 100-day benefit for skilled nursing facility (SNF)care.
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 an E2300 power seat elevation system.
You asked the Plan to pre-approve a power wheelchair with an E2300 power seat elevation system. The Plan denied your request. The Plan says while the power wheelchair and Medicare allowed accessories were approved, the E2300 power seat elevation system is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare specifically states an E2300 power seat elevation system is not a covered accessory. Therefore, we decided that the Plan does not have to pre-approve an E2300 power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRIs of the lumbar and cervical spine.

You asked the Plan to pre-approve the MRIs. You say that you would like reconsideration because these examinations are medically necessary. The Plan denied your request. The Plan says there is no indication for MRI to evaluate routine pain which is responding to treatment.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRIs. Our reviewer says that there is no evidence of unusual findings to support the necessity of the MRI examinations of the cervical and lumbar spine. Our physician reviewer found medical necessity is not established for the MRI examinations in question.

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 MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve MRIs of the lumbar and cervical spine.