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

We decided that the Plan does not have to pre-approve gradient compression stocking/sleeve identified with
code A6549.
You asked the Plan to pre-approve the gradient compression stocking/sleeve. You say that the enclosed
documents from physicians supports the need for continued use of the prescribed equipment. The Plan denied
your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
non-covered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient
compression stocking/sleeve identified with code A6549.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to payforskilled nursing facility (SNF) services provided to the enrollee from March 1, 2019 to March 18, 2019.You asked the Plan to pay forthese services. You say that SNF services were medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria were not 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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records show the enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee didnot require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment at a SNF level. The enrollee did not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". Medicare coverage criteria were not met.  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 pay forskilled nursing facility (SNF) services provided to the enrollee from March 1, 2019 to March 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided on September 9, 2019.You asked the Plan to pay forthe prophylaxis and periodic oral evaluation. You say that you go to the dentist every 6 months. You also say that this should not be denied because you went a few days early.The Plan denied your request. The Plan says these procedures are only covered once every 6 months.Medicare generally does not cover dental services. However, the Plan offers a dental benefitthat 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, oral exams and cleanings are limited to one every 6 months. The record shows that you received a prophylaxis and periodic oral evaluation on March 18, 2019, and your oral exam and cleaning benefits were then exhausted for the 6 month period.Therefore, we decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided on September 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the observation stay provided from September 2, 2019 through September 4, 2019.
You asked the Plan to waive the cost share for the observation stay. You say that you were very sick and went to the hospital to get answers. You say that insurance should cover these charges. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Your contract with the Plan says that after you pay your $1,000 deductible you pay a $250 copayment for in-network outpatient hospital observation services. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000, deductible applies to outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the observation stay was received from September 2, 2019 to September 4, 2019. Therefore, the remaining amount was applied to your deductible.
Since you met your $1,000 deductible, you have also been asked to pay a $250 copayment for the observation stay. 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 cost share for the observation stay provided from September 2, 2019 through September 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from May 3, 2019 to May 15, 2019 and from May 21, 2019 to May 31, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services provided from May 3, 2019 to May 15, 2019 and from May 21, 2019 to May 31, 2019. Our reviewer says that theenrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did nothave daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services provided from May 3, 2019 to May 15, 2019 and from May 21, 2019 to May 31, 2019 have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from May 3, 2019 to May 15, 2019 and from May 21, 2019 to May 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic polysomnography services.
You asked the Plan to pre-approve the diagnostic polysomnography services. You say that periodic leg syndrome would be diagnosed with a sleep study. The Plan denied your request. The Plan says the records provided do not support that the criteria for coverage have 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 pre-approve the diagnostic polysomnography services. Our reviewer says that diagnostic polysomnography services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has leg jerking when resting or sleeping. Restless leg syndrome (RLS), or periodic limb movement disorder, is suspected. Diagnostic criteria have been published. Polysomnography services are not necessary to diagnose RLS. 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 diagnostic polysomnography services have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic polysomnography services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on September 17, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 forthe emergency room visit provided on September 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genicular Nerve Radiofrequency Ablation (64640).
You asked the Plan to pre-approve Genicular Nerve Radiofrequency Ablation. You say that you have exhausted other treatments. The Plan denied your request. The Plan says this is experimental.
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 Genicular Nerve Radiofrequency Ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is experimental. More research is needed to show it is effective for treating your condition before it can be considered 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 Genicular Nerve Radiofrequency Ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve Genicular Nerve Radiofrequency Ablation (64640).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift home modification.
You asked the Plan to pre-approve the stair lift. You say that you need to be able to remove the ashes from the coal stove in the basement two times per day, and you cannot carry the ashes and use the stair railing at the same time. The Plan denied your request. The Plan says the item at issue is not considered medically necessary, and not the most conservative measure to address your needs.
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 stair lift. Our reviewer says that the requested stair lift is not medically reasonable and necessary in this case, according to the coverage criteria established by the CFR. Our physician reviewer found you are independent with all activities of daily living and instrumental activities of daily living. You report compliance with medical providers and medications. During your recent physical with your physician you stated, "everything is fine", you report you continue to work as a cab driver part time, you enjoy your job and still feel productive. The medical records provided do not meet the requirements listed in the CFR for Medicare coverage of the stair lift home modification. 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 stair lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a stair lift home modification.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene analysis and molecular pathology procedure provided on October 24, 2019 by an OON provider.
You asked the Plan to pay for the gene analysis and molecular pathology procedure. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that 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 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 the gene analysis and molecular pathology procedure provided on October 24, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on April 18, 2019.You asked the Plan to pay fordrug 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 include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab tests is required for covered lab tests. 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 tests 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 fordrug testing provided on April 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 5, 2019 to June 30, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says no skilled rehabilitation services were provided during this time frame.
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 pay for the skilled nursing services provided from June 5, 2019 to June 30, 2019. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services provided from June 5, 2019 to June 30, 2019 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 5, 2019 to June 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78452).
You asked the Plan to pre-approve the Myocardial Perfusion Imaging. You say that the service is medically necessary. The Plan denied your request. The Plan says rules for coverage have not 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 pre-approve the Myocardial Perfusion Imaging. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stent placement about 1 year ago with no documented symptomatic or objective evidence of coronary ischemia since that time. In this setting of a clinically stable patient without symptoms of coronary ischemia Myocardial Perfusion Imaging is not considered 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 Myocardial Perfusion Imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78452).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 1, 2019.
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 not billed correctly.
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 an independent laboratory; 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 to on April 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe air ambulance services provided on November 5, 2019.You asked the Plan to pay forthe air ambulance services. You say that the air ambulance service was medically necessary.The Plan denied your request. The Plan says the air ambulance service was not medically necessary.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our physician reviewer found that the health plan's denial should be upheld.  The enrollee transferred from one facility to another for services not available at the sending facility. While the transfer itself was medically necessary and reasonable, the use of an air ambulance to conduct the transfer does not appear to have been medically necessary or reasonable.  The enrollee's injury occurred on November 3, 2019.  Theenrollee spent two days at the sending facility undergoing surgery and eating, prior to be transferred.  The enrollee appears to have been hemodynamically stable and neurologically intact.  It appears that transfer via a properly equipped ground ambulancewould have been safe and reasonable.  The use of an air ambulance to transport the enrollee was not medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the air ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe air ambulance services provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee orthoses.
You asked the Plan to pre-approve knee orthoses (L1845). You say that you need the knee orthoses to support your knees for walking and to prevent falling. The Plan denied your request. The Plan says criteria was not met for knee orthoses.
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 knee orthoses (L1845). Our physician reviewer found based on the documentation provided the health plan's denial should be upheld. The enrollee is noted to have bilateral knee pain attributed to osteoarthritis. There is no evidence of joint deformity, joint laxity, joint instability, recent injury or recent surgery. As such, the documentation does not support that the requested orthoses are medically necessary or reasonable. 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 knee orthoses (L1845) have not been met. Therefore, we decided that the Plan does not have to pre-approve knee orthoses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts.
You asked the Plan to pre-approve foot inserts (L3000). You say that the enrollee needs the orthotics for ambulation. The Plan denied your request. The Plan says the foot inserts are not a covered benefit as they are not for a shoe that is an integral part of a leg brace.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a shoe that is part of a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity injection
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Trulicity injection