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

We decided that the Plan does not have to pay for the CPAP supplies provided by an out of network (OON) supplier.

You asked the Plan to pay for the CPAP supplies. You say that this is a valid claim. The Plan denied your request. The Plan says this supplier/provider is not in network and there are multiple suppliers/providers in the area where you could have obtained these supplies.

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 CPAP supplies provided by an out of network (OON) supplier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that the enrollee has established care for more than a year with this physician and needs to continue care with him directly. The Plan denied your request. The Plan says that the Plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network. The enrollee must receive care from a network provider. In most cases, care received from an out-of-network provider will not be covered.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0475) provided on June 16, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was submitted with an inappropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that Current Procedural Terminology (CPT) code E0475 is not supported in the record. Specifically, per Medicare, this item is a capped rental item. This claim was billed with a modifier to indicate that this is new equipment. This is not an appropriate modifier for a capped rental item. Based on this information, we decided that Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0475) provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain provided on July 20, 2020.
You asked the Plan to pay for the emergency treatment of dental pain. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.
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 pay for the palliative (emergency) treatment of dental pain provided on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was medically necessary. The Plan denied your request. The Plan says that inpatient services were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection.

You asked the Plan to waive the coinsurance for these services. You say that you were informed by the provider that the injections would be covered. The Plan denied your request. The Plan says the 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 chemotherapy and all other drugs covered under Medicare Part B.

Review of the file shows that you received a Prolia injection. You have been asked to pay a 20% coinsurance for these services. These services fall within the chemotherapy and all other drugs covered under Medicare Part B benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan is not denying coverage of these services. The amount you are being asked to pay is the 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 for the Prolia injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Prolia. Our reviewer says that the member has not used zoledronic acid. Our physician reviewer found there is no indication that zoledronic acid would likely be less effective and/or likely have adverse effects for the member. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on September 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
You asked the Plan to pre-approve 4 additional physical therapy visits. You say that the requested 4 additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the requested 4 additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 4 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the documentation does not indicate that her functional level or deficits on exam require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveunlimited supplemental transportation trips.You asked the Plan to pre-approvethe unlimited transport trips. You say that you need unlimited trips to other destinations.The Plan denied your request. The Plan says unlimited transportation is only provided to Primary Care offices. Transportation to other destinations is limited to 48 one-way trips.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 thiscase. The Plan covers a maximum of 48 trips per year to locations other than primary care offices. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the plan does not need to pre-approve unlimited transportation to locations other than the primary care office.Therefore, we decided that the Plan does not have to pre-approveunlimited supplemental transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe device. You say that the enrollee has pain with standing, walking, lifting, and climbing stairs.The Plandenied your request. The Plansaysthis device is still being studied to determine safety and efficacy.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device remains experimental. More research is needed to show safety and efficacy of the device.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0636).

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit for the shoulder.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. 

You have not had total knee replacement surgery. This is being requested for a shoulder problem. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0636).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the hip x-ray (73501) provided on September 8, 2020.
You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration because this service was denied as a duplicate in error. The Plan denied your request. The Plan says that this service is a column II code to another code that was billed on the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 73501 is supported in the record. Specifically, the record indicates that the column I and column II codes were rendered by different providers. Column I and column II edits are not appropriate for services rendered by different providers. Based on this information, we decided that Medicare rules for coverage of the hip x-ray have been met. Therefore, we decided that the Plan has to pay for the hip x-ray (73501) provided on September 8, 2020.
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 you would like reconsideration because this IRF admission is medically necessary. The Plan denied your request. The Plan says the member's care may be safely rendered in an alternate level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital the member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. She requires intermittent skilled therapy services to improve function and prevent deterioration, however she is able to ambulate up to 100 feet. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. Admission to a SNF for inpatient skilled care 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313),
electric connection (E2311) and joystick controller (K0108).
You asked the Plan to pre-approve the wheelchair supplies. You say that you would like reconsideration
because this equipment is medically necessary. The Plan denied your request. The Plan says there is not a
medical need to control power options through the joystick.
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 wheelchair supplies. 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 reveal that you require other types of proportional input
devices or non-proportional input devices. You do not need to operate three or more powered seating actuators
through the drive control, a separate display, other electronic devices, or an attendant control. Your upper
extremity function is sufficient to control any power options through your own individual switches therefore
the requested items are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the wheelchair supplies have not been met. Therefore, we decided that the Plan
does not have to pre-approve the expandable controller (E2377), harness (E2313), electric connection (E2311)
and joystick controller (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures you received on January 13, 2017.
You asked the Plan to pay for the dentures. The Plan denied your request. The Plan says this requested exceeds the benefit limit.
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 services are subject to a benefit limitation. The Plan covers one denture every five years. The records show that you received a covered denture on December 22, 2016. This means that the requested dentures exceed the benefit limit, and are not covered. Therefore, we decided that the Plan does not have to pay for the dentures you received on January 13, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean occlusal guard (D9944).You asked the Plan to pre-approvethe occlusal guard. The Plan denied your request. The Plan says this service is not covered.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-approvean occlusal guard (D9944).