Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you would like approval for this office visit. The Plan denied your request. The Plan says there are in-network providers available for these 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the records provided support the need for the requested CGM. The Plan denied your request. The Plan says that the records do not show that the enrollee has been consistently checking their blood sugar at least 4 times daily or adjusting insulin based on the blood sugar levels.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.
We 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 CGM. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee is on 4 shots per day and checks blood glucose levels 4 times per day. Although the a1c suggests an average blood glucose of 275, the enrollee may likely be having high blood glucose levels after supper. Therefore, the reports blood glucose levels which suggest an average closer to 200 should not call into question the accuracy of his reported blood glucose level check frequency. The requested CGM will likely make it easier to check 4 times a day or even more often. Given the number of medications for diabetes the enrollee is on, and the complexity of his regimen, this frequency is desired and 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 CGM have been met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 electric lift for the enrollee.
You asked the Plan to pre-approve an electric lift. You say that you cannot longer get your husband out of bed.
The Plan denied your request. The Plan says that they do not cover duplicate or redundant durable medical
equipment.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has a mechanical lift. A mechanical lift serves the same purpose as an electric
lift. Therefore, we decided that the Plan does not have to pre-approve an electric lift for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services (72114, 82550, 83516, 86225, 86226, 86235) provided July 8, 2019.
You asked the Plan to pay for the diagnostic services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the codes 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 72114, 82550, 83516, 86225, 86226, 86235 is not supported in the medical record. Specifically, the records provided do not support the services that were billed. X-ray and lab reports were not provided to show these services were actually performed on the date of service. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic services (72114, 82550, 83516, 86225, 86226, 86235) provided July 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an additional 160 units of skin grafts.
You asked the Plan to pre-approve the additional units. You say that this is medically necessary to treat the enrollee's left foot ulcer. The Plan denied your request. The Plan says that this is unproven.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional units. Our reviewer says that the additional units are considered medically reasonable and necessary in this case. Our physician reviewer found the additional units at issue in this case medically reasonable and necessary, due to the need for additional skin grafting. 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 additional units have been met. Therefore, we decided that the Plan has to pre-approve an additional 160 units of skin grafts.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 7.
You asked the Plan to pre-approve the dental service. You say that the enrollee has a large existing composite on tooth # 7. You say that a full coverage crown is indicated at this time as poor marginal adaptation of composite has resulted in staining and recurrent decay. The Plan denied your request. The Plan says that the crown is not medically necessary. The Plan also says there is no evidence of pathologic destruction of the tooth warranting a crown.
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 the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested crown is medically necessary. Our physician reviewer found the provided documentation indicates the presence of a completed root canal on tooth # 7. The reviewer also found there is a large restoration present with recurrent caries. The reviewer found that the structural integrity of the tooth with a root canal is compromised due to the coronal access for the treatment. Therefore, the requested crown is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth # 7.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for echocardiography (93306) provided on October 17, 2019.
You asked the Plan to pay for the echocardiography. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says it is the provider's responsibility to bill the
Plan or any liability insurance before submitted the claim to the member's plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the echocardiography until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for echocardiography (93306) provided on October 17, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services.
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 that the claim contains invalid data or is missing data that is required by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the claims were billed with invalid or missing data; however, there is no further explanation as to which documentation was billed incorrectly or was missing. The Plan has not provided any clear denial reason or evidence to support that the claims are not payable as billed. Therefore, we decided that the Plan has to pay for the home health services.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services provided on November 8, 2009 and a hospital inpatient admission provided from November 8, 2019 to November 9, 2019.
You asked the Plan to waive the copayment for the emergency department services and a hospital inpatient admission. You say that you were admitted to the hospital at 5:00 p.m. on November 8, 2019 and you were transferred to another hospital at 11:30 p.m. on November 9, 2019. You say you were in the hospital for one day and not three days. The Plan denied your request. The Plan says the claim processed with the correct copayment.
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 $90 copayment per visit for emergency services and you must pay a $250 copayment per day for days 1-6 per admission for inpatient hospital care. You have been asked to pay $90 copayment per visit for emergency services and a $250 copayment per day for
days 1-6 per hospital inpatient admission. The emergency department services and a hospital inpatient admission falls within the emergency care and inpatient hospital 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 the emergency department services provided on November 8, 2009
and a hospital inpatient admission provided from November 8, 2019 to November 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided from September 15,
2019 to October 13, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says these
services can be rendered within the Plan's network. These services do not fall within the exception of
emergency or urgently needed services and a prior authorization is required.
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
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 nurse practitioner services provided from September 15, 2019 to
October 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on December 17, 2019.You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The Plan states payment for these services is the responsibility of the facility.The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment.Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided from October 18, 2019 to October 21, 2019.You asked the Plan to pay forinpatient mental health care. You say that that this was medically necessary.The Plan denied your request. The Plan says care after October 17, 2019 was not authorized or necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 payfor inpatient mental health care. Our reviewer says that inpatient care was not medically necessary for the dates at issue. Our physician reviewer found the records show that it was not expected this enrollee would improve in a reasonable period of time beyond the dates the Plan has approved as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care for the dates 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 inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided from October 18, 2019 to October 21, 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 60 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Euflexxa. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the records do not show a trial of the plan preferred agents or any reason why they would be contraindicated 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 10, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 20, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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. Your annual dental maximum of $2000 was met on the claim from date of service January 20, 2020. The dental maximum was exceeded by $331.00. Since the claim has paid correctly, any amount over the dental annual maximum would be owed to the provider. Your EOC states, you have a $2,000 annual maximum. After the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 20, 2020.