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

We decided that the Plan does not have to pre-approve the four-point transit package, anterior trunk support
strap guide, and soft oval pad.

You asked the Plan to pre-approve the four-point transit package, anterior trunk support strap guide, and soft
oval pad. You say that these services are medically necessary. The Plan denied your request. The Plan says
these items are not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home. The rules also 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 rules also say that for equipment to be covered, it must primarily serve a
medical purpose.

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 for the 4-point transit package, anterior trunk support
strap guide, and soft oval pad. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the transit kit is primarily meant to be used
outside the home. In addition, the oval pad is not primarily medical in nature. Finally, the trunk support is a
duplicate request for DME already available to the enrollee.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve the four-point transit package, anterior trunk support strap guide, and soft oval pad.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that HBOT is covered for specific indications only. 

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 the services are medically necessary. Our physician reviewer found the enrollee has non-healing diabetic ulcers of the right foot. The wounds have not displayed signs of healing over the past 30 days despite standard wound care, antibiotic treatment, and correction of poor blood flow. The enrollee has a covered diagnosis for HBOT without measurable signs of healing in a 30-day period and the services are medically necessary at this time. 

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 been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.

You asked the Plan to waive the copayment for the ambulance services. You say that you did not want to be transported to the hospital but you were advised that you had to go. The Plan denied your request. The Plan says you were charged this cost sharing 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 $175 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $175 for these services. 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 ambulance services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health private nursing care.

You asked the Plan to pre-approve home health private nursing care. You say that you need home health nursing care. The Plan denied your request. The Plan says your needs are custodial rather than skilled nursing needs.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health private nursing care. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Your needs are custodial.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health private nursing care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health private nursing care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for an infusion pump and supplies (HCPCS A4222 and HCPCS E0781) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services performed are inclusive of services already paid and approved.

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 the denied codes is:

HCPCS A4222: 

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately).

HCPCS E0781:

Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient.

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the equipment and supplies provided to the enrollee would not be billed separate from the provider, supplying the equipment and supplies, this is considered unbundling. Therefore, supplier would bill provider for services.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for an infusion pump and supplies (HCPCS A4222 and HCPCS E0781) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4222, E0781, A4221).

You asked the Plan to pay for infusion supplies. You say that these items were medically necessary. The Plan
denied your request. The Plan says these items are not separately billable or payable from the chemotherapy
infusion.

The Plan must follow Medicare rules. Medicare rules say that when medical and surgical supplies described by
HCPCS codes with status indicators other than "H" or "N" are provided incident to a physician's service by a
hospital outpatient department, the HCPCS codes for these items should not be reported because these items
represent supplies.

We looked at the file and Medicare rules. The records show that the supplies at issue were provided incident to
the physician's service of chemotherapy infusion and are not separately payable. Based on this information, we
decided that Medicare rules for coverage of infusion supplies have not been met. Therefore, we decided that the
Plan does not have to pay for infusion supplies (A4222, E0781, A4221).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.

You asked the Plan to pre-approve additional PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that in the case of rehabilitative therapy, the patient's condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

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 additional PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the documentation does not indicate that her functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The documentation reveals groin pain has been contributing to the enrollee's lack of significant progression in therapy. There is no evidence of a physician evaluation of the groin pain. The enrollee has been educated in home safety. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve frames (V2020).

You asked the Plan to pre-approve frames. You say that you lost your pair of glasses and should be able to get them replaced. The Plan denied your request. The Plan says you have exhausted your plan benefit for this service.

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 one pair of eyeglasses or contact lenses per a plan year. 

We looked at the file and the Plan's rules. You have already received your benefit maximum for this service. Based on this information, we decided that the Plan's rules for coverage of frames have not been met. Specifically, records show you have already received a pair of eyeglasses this plan year. This means you have exhausted the Plan benefit and the item is not covered. Therefore, we decided that the Plan does not have to pre-approve frames (V2020).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal epidural (64483).

You asked the Plan to pre-approve a lumbar/sacral transforaminal epidural. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are generally performed to treat pain arising from spinal nerve roots. 

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 a lumbar/sacral transforaminal epidural. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, you had an injection for lumbar sacral pain. The provided documentation was completed with a notation to schedule the injection. No further documentation is provided. The provided documentation is insufficient to meet the requirements as an assessment three months following the initial injection is not provided.

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 lumbar/sacral transforaminal epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal epidural (64483).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography (CT), thorax
(71250).

You asked the Plan to waive the copayment for the CT scan. You say that you were sent to the hospital to have
the CT scan done by your doctor. You were not aware that you were going to have a copay for this service. The
Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the
Evidence of Coverage.

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 $208.99
$225 copay for advanced imaging services for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay $208.99 $225 copay for advanced imaging services for the CT scan. Since the
allowed amount is less than the $225 copay amount, you are responsible for the lesser amount. the CT scan
falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT), thorax (71250).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate 2.5 mg tablet.

You asked the Plan to pre-approve Methotrexate. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the member's medical benefit.

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 Methotrexate 2.5 mg tablet.

Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73000).

You asked the Plan to pay for an x-ray. You say that this is supported in the records. The Plan denied your request. The Plan says this claim must be submitted to the enrollee's primary insurance.

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 an x-ray until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an x-ray (73000).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric services (90792).

You asked the Plan to pay for the psychiatric services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the psychiatric services was not filed until September 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychiatric services (90792).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment
supported crown (D6058).

You asked the Plan to pay for the dental services. You say that just because something improves your
appearance does not mean that it is unnecessary. You say that you were in an accident which shattered a front
tooth. You say that you also need a few implants. You also say that you would like at least the crowns to be
covered. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered
service. The Plan says that abutment supported crown is not listed as a covered service either. The Plan also
says that although there is coverage for a crown, there is no coverage for an abutment or a crown used for a
bridge.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
custom fabricated abutment (D6057) and the abutment supported crown (D6058).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transfer services.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

Transfer to another facility via ambulance is not an emergent and necessary service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transfer services