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

We decided that the Plan does not have to pre-approve repair procedures on the nose, septoplasty (30520).

You asked the Plan to pre-approve septoplasty. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee did not meet the medically necessity criteria for approval.

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 septoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with a deviated nasal septum, but physical exam findings from 2 separate office visits state that the nasal septum is midline. The CT scan notes a deviated nasal septum, but it is unclear if this is clinically relevant. There is no documentation that the enrollee needs the deviated septum to be addressed. He is not complaining of nasal obstruction or difficulty breathing through his nose. Therefore, the enrollee does not meet criteria or medical necessity for this surgery.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of septoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve repair procedures on the nose, septoplasty (30520).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 4, 2020.

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 the services are not covered.

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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided September 15, 2020.
You asked the Plan to pay for the CGM supply allowance. You say that you are attaching documentation which supports the fact that the enrollee was treated by the physician. The Plan denied your request. The Plan says the services are not supported in the medical records received.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. There is no proof of delivery and no signature on the tracking sheet. The plan has also attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total shoulder arthroplasty.
You asked the Plan to pre-approve the acute inpatient hospital care. You say that an inpatient hospital admission is medically necessary for the enrollee. The Plan denied your request. The Plan says an inpatient hospital admission is 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 pre-approve the acute inpatient hospital care. Our reviewer says that an inpatient hospital admission is not medically necessary. Our physician reviewer found that the enrollee presents with chronic, debilitating, left shoulder pain secondary to advanced osteoarthritis. He has tried and failed conservative treatments. The enrollee is undergoing a planned shoulder arthroplasty. He is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation that the enrollee will require a greater than two midnight stay.
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 not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthotics provided on August 6, 2020.
You asked the Plan to pay for knee orthotics. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the packing slip submitted did not include the carrier's tracking number nor did the proof of delivery include details to corroborate the delivery ticket submitted.
The Plan must follow Medicare rules. Medicare rules say that a Plan may require proof of delivery in order to verify that the beneficiary received billed DMEPOS items. We looked at the file and Medicare rules. The documentation submitted does not include proof of delivery of the specific items billed on this claim. Based on this information, we decided that Medicare rules for coverage of knee orthotics have not been met. Therefore, we decided that the Plan does not have to pay for knee orthotics provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on
December 2, 2020.
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The
Plan says the correct copayment was applied to the claim.
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
copayment for Vision Care, for exams to diagnose and treat diseases and conditions of the eye by an
ophthalmologist.
You have been asked to pay for the physician's services. The physician's services falls within the Vision Care
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 physician's services provided by
on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781) provided January 16, 2020.

You asked the Plan to pay for the progressive lenses. You say that the progressive lenses should be covered under your routine eyewear allowance. The Plan denied your request. The Plan says progressive lenses are not considered routine eyewear and therefore are not covered under your routine eyewear allowance.

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.

We looked at the file and the Plan's rules. Though the Plan offers a vision benefit in excess of Medicare coverage, progressive lenses are not among those covered under this benefit. Based on this information, we decided that the Plan does not have to pay for the progressive lenses (V2781) provided January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid received from an out-of-network provider.
You asked the Plan to pay for the hearing aid. You say that the hearing aid was necessary. The Plan denied your request. The Plan says you must obtain your hearing aids from a Nations Hearing provider.
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 when purchased from a Nations Hearing provider. 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 the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid received from an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit, noninvasive ear or pulse oximetry for oxygen saturation, eligible clinician, patient screening, falls risk assessment, chronic care management, medication services, vital signs, weight recording, BMI, blood pressure measurement, systolic blood pressure, diastolic blood pressure, oxygen saturation, and pain severity service provided on November 17, 2020 by an OON provider.
You asked the Plan to pay for the medical services. You say that you would like the provider to be reimbursed for the services that were rendered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the enrollee was referred by a non-participating provider, and prior authorization was not obtained.
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 home visit, noninvasive ear or pulse oximetry for oxygen saturation, eligible clinician, patient screening, falls risk assessment, chronic care management, medication services, vital signs, weight recording, BMI, blood pressure measurement, systolic blood pressure,
diastolic blood pressure, oxygen saturation, and pain severity service provided on November 17, 2020 by an OON provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99335) provided on
November 28, 2020, by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that claim denied as
precertification/authorization absent. Hence the claim has been appealed with medical records for the date of
service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in network
provider with the exception being urgent or emergent services. Non-emergent services with non contracted
providers require prior authorization before services being rendered.

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 domiciliary or rest home visit (99335) provided on
November 28, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 3, 2020.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cochlear implant (L8614, 69930).
You asked the Plan to pre-approve a cochlear implant. You say that other treatments have not worked. The
Plan denied your request. The Plan says the enrollee does not have bilateral hearing loss.
The Plan must follow Medicare rules. Medicare rules say that cochlear implantation may be covered for
treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals
who demonstrate limited benefit from amplification.
We looked at the file and Medicare rules. The record shows that the enrollee does not have bilateral hearing
loss. Based on this information, we decided that Medicare rules for coverage of a cochlear implant have not
been met. Therefore, we decided that the Plan does not have to pre-approve a cochlear implant (L8614, 69930).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that your previous physician referred you because you have irregular moles. The Plan denied your request. The Plan says the provider is out of 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 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 office visit provided on November 17, 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 IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 acute hypoxic respiratory failure, congestive heart failure, sepsis, and pneumonia. 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you need physical therapy. The Plan denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital and underwent heart surgery on April 23, 2021. The most recent therapy notes show that you need assistance with bed mobility and transfers and can walk 360 feet with assistance. You are medically stable and have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 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 skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power wheelchair accessory, u-1 sealed lead acid battery (E2365) sales tax (S9999) provided on September 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the power wheelchair battery and sales tax. You say that you went to visit family in Charlotte, North Carolina and you had to buy emergency batteries. You spoke to a representative before you filed, and they said you did not need a doctor authorization for batteries. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. The provider does not participate with Medicare. Sales tax is not covered by Medicare or 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 does not participate with Medicare. 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 power wheelchair accessory, u-1 sealed lead acid battery (E2365) sales tax (S9999) provided on September 5, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the additional intraoral x-rays (D0230 x 2) provided on December 7, 2020.
You asked the Plan to pay the in network rate for the 2 additional periapical x-rays. You say that you are not able to afford to pay the out of network rate for these services. You say that you did not know that the dentist was out of network. The Plan denied your request. The Plan says 1 intraoral x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and intraoral x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial intraoral x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay the in network rate for the additional intraoral x-rays (D0230 x 2) provided on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (G0481) provided July 1, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code G0481 is not supported in the medical record. Specifically, the claim shows a place of service 81, laboratory. The records show that the sample was obtained in the office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (G0481) provided July 1, 2020.