Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for
transfer to an LTACH. You say that the enrollee cannot be cared for in his current condition at a lower level of
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says
that the care needed can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
sepsis attributed to pneumonia, a UTI and infectious diarrhea. The enrollee was intubated/ventilated and
subsequently received a tracheotomy. The enrollee is currently tolerating ventilator weaning. There is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a
time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care
for any ongoing long term care needs.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bifocal lens (V2203) tint, photochromatic lens (V2744)
balance lens (V2700) purchased January 3, 2020.
You asked the Plan to pay for the vision services. You say that you had cataract surgery May 31, 2019. After
the cataract surgery you had retinal surgery which prevented you getting the eye glasses sooner. The Plan
denied your request. The Plan says these services are upgrades and are not covered under the plan benefits.
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 these services when covered eyeglasses after cataract surgery includes standard
frames as lenses. Upgrades are not covered.
We looked at the file and the Plan's rules. Upgrades are not covered (including but not limited to deluxe frames,
tinting, progressive lenses or anti-reflective coating). Based on this information, we decided that the Plan's
rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have
to pay for bifocal lens (V2203) tint, photochromatic lens (V2744) balance lens (V2700) purchased January 3,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided February 3, 2020.

You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.

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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a shoulder problem, and there is no credible physical examination of the shoulder.

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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership fee purchased December 31, 2019.
You asked the Plan to pay for gym membership. You say that you knee the dues were coming so you started to
fill out the application the end of December 2019 so you wouldn't be late. The Plan denied your request. The
Plan says payment is only eligible for reimbursement during the plan year in which the payment is made.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Gym benefits is only eligible
for reimbursement during the plan year in which the payment is made. Records show that you paid for gym
membership on January 4, 2019 and was reimbursed in January, 2019. You paid for your gym membership
renewal on December 30, 2019. As the plan had already reimbursed for the 2019 year, an additional $240
cannot be reimbursed.
The Plan's rules for coverage of gym benefits have not been met because payment is only eligible for
reimbursement during the plan year in which the payment is made. Therefore, we decided that the Plan does
not have to pay for the gym membership fee purchased December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided on August 14, 2019
to November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the home infusion therapy services provided out of network. You say that the
code in dispute is not a DME and was not delivered to the enrollee's home. You say that the information sent to
you from the enrollee's physician office supports that the medication was delivered to the Plan participating
physician's office. The Plan denied your request. The Plan says the services denied because the provider who
supplied the home infusion services is non-participating.
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 has network providers
available who can provide 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 home infusion therapy services provided on
August 14, 2019 to November 20, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ground ambulance services provided on November 13, 2019.
You asked the Plan to pay for the ground ambulance services. You say that you had no other way to get to the
hospital. The Plan denied your request. The Plan says there were closer facilities available to manage your
condition.
Medicare pays for ambulance services only when transported to the nearest appropriate facility. The Plan
follows the same rules.
We looked at the file and Medicare rules. You were not transported to the nearest hospital capable of furnishing
the required care. Based on this information, we decided that Medicare rules for coverage of the ground
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ground
ambulance services provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Novolog.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is higher than it
should be. 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 Part B covered drugs.
The services at issue are Novolog. Per the contract with the Plan, there is a 20% coinsurance for these services.
These services fall within the Part B covered drugs benefit category. This means that you will be 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 for Novolog.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested enteral nutrition supplement, Ensure Original.
You asked the Plan to pre-approve the enteral nutrition supplement, Ensure Original. The Plan denied your request. The Plan says the enrollee must use network providers to get covered services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve the requested enteral nutrition supplement, Ensure Original.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device
(E0730) provided June 18, 2019 to October 1, 2019.
You asked the Plan to pay for the TENS device. You say that please reconsider the claims for payment to avoid
interruption of the enrollee's treatment. The Plan denied your request. The Plan says procedure code E0730 has
not met the associated Modified Code Relation per LCD L33802.
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 E0730 is transcutaneous electrical nerve stimulation
(tens) device, four or more leads, for multiple nerve stimulation.
Per LCA A52520 claim lines billed for E0720, E0730, and E0731 without a GA, GZ or KX modifier as
specified above will be rejected as missing information. Based on this information, we decided that Medicare
rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to
pay for transcutaneous electrical nerve stimulation (tens) device (E0730) provided June 18, 2019 to October 1,
2019.
We note that it appears a corrected claim was during the review of this case. We cannot act on or process claim
corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only
permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit
any corrections or additional claim information directly to the Plan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray for the shoulder billed with CPT code 73030 for date of service December 4, 2019.
You asked the Plan to pay for the x-ray of the shoulder. You say that the enrollee had multiple exams on this date of service. You say that the attached reports support the level of service in dispute. The Plan denied your request. The Plan says the clinical case notes and records only support payment for 1 unit of 73030-TC-RT, which was previously paid. The Plan says that there is no additional documentation supporting an additional imaging study. The Plan says that the reports submitted are duplicates of each other and that this is a billing issue.
The Plan must follow Medicare rules. Medicare rules say that providers must supply information that corroborates the documentation in the enrollee's medical documentation and confirms that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The records show that the plan paid a claim for one unit of the noted service. There is insufficient documentation provided to show that an additional shoulder x-ray was performed on the noted date of service. Therefore, we decided that the Plan does not have to pay for an x-ray for the shoulder billed with CPT code 73030 for date of service December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus Solostar 100 unit/ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says given the current information, this drug is not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus Solostar 100 unit/ml
for the enrollee.
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. The Plan denied your request. The Plan says IRF admission 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 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 that the enrollee was medically stable with no evidence of need for supervision by PMR Physician or need for acute rehab nursing care. There is no medical complexity and he does not need IRF level therapies. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a trunk flap (15734) provided on August 27, 2019.

You asked the Plan to pay for a trunk flap. You say that this should be reconsidered. The Plan denied your request. The Plan says this code was not documented in the operative report.

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 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk.

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 a trunk flap. Our reviewer says that this code is not supported. Our physician reviewer found the description of this procedure was not documented in the operative note of the patient's record. Also, a flap that contains muscle or fascia does not constitute a true advancement flap. CPT code 15734 is reserved for axial pattern flaps.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a trunk flap have not been met. Therefore, we decided that the Plan does not have to pay for a trunk flap (15734) provided on August 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from November
25, 2019 through December 18, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that some visits were covered and
others weren't. You say that you thought your plan covered all rehabilitation visits. The Plan denied your
request. The Plan says the copayments 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 $40
copayment for Medicare-covered physical therapy. You have been asked to pay a total of $360 for physical therapy. ($40/visit x 9 visits = $360). Physical therapy
falls within the "Outpatient rehabilitation 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 physical therapy provided from November 25, 2019 through December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on January 6, 2020.
You asked the Plan to pay for dental service. You say that this provider is an American citizen, but her office is
out of the country. You also say that there is no requirement that you have dental service done in the United
States of America. The Plan denied your request. The Plan says the denial of payment for this service is
correct, because this service was performed outside of the United States of America and was not emergent or
urgent in nature.
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the
United States of America are excluded from coverage, except in certain specific circumstances. The Plan has a
supplemental benefit for worldwide coverage that goes beyond Medicare's benefit. The Plan offers worldwide
coverage for emergency and urgent care services furnished outside of the United States of America if the
enrollee reasonably thought their health was in serious danger.
We looked at the file, Medicare rules, and the Plan's rules. The services provided do not meet any of the
specific coverage conditions for Medicare's coverage of out-of-country services. You elected to leave the
United States of America for the purposes of obtaining this service, therefore this service would not be urgent
or emergent in nature. Based on this information, we decided that neither Medicare's nor the Plan's rules for
coverage of out-of-country services have been met. Therefore, we decided that the Plan does not have to pay
for dental services provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 9, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for these tests.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 9, 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. The Plan denied your request. The Plan says IRF admission 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status is not stable for a transfer due to distended abdomen and need for possible paracentesis.
The enrollee may benefit from additional multiple therapies, however the enrollee's functional level currently
does not require that this therapy must be in an IRF with an intensive level program.
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.