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

We decided that the Plan does not have to pre-approve the calf panel (K0108), expandable controller and harness (E2377, E2313), and attendant control (E2331).
You asked the Plan to pre-approve a group 3 power wheelchair with multiple accessories. You say that these items are medically necessary for the well-being of the enrollee. The Plan denied your request. The Plan says these items/services are not medically necessary.
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 calf panel, expandable controller and harness, and attendant control. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record indicates that the enrollee has normal upper body strength and sensation on physical examination. The medical record does not support the medical necessity and reasonableness, as defined my Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 calf panel, expandable controller and harness, and attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve the calf panel (K0108), expandable controller and harness (E2377, E2313), and attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Omnipod disposable external insulin delivery system (A9274).
You asked the Plan to pre-approve an Omnipod disposable external insulin delivery system (A9274). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the requested item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare guidelines say that disposable drug delivery systems (A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. Based on this information, we decided that Medicare rules for coverage of an Omnipod disposable external insulin delivery system (A9274) have not been met. Therefore, we decided that the Plan does not have to pre-approve an Omnipod disposable external insulin delivery system (A9274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus/diphtheria/acellular pertussis (Tdap) vaccine provided on February 17, 2021.
You asked the Plan to pay for the Tdap vaccine. You say that this should be covered. The Plan denied your request. The Plan says this vaccine is not among those covered by Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus/diphtheria/acellular pertussis (Tdap) vaccine provided on February 17, 2021.
Benefits for the Tdap vaccine 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services provided on January
18, 2021 by an OON provider.

You asked the Plan to pay for the chronic care management services. You say that the enrollee did not have
many options to choose another provider in the area that was able to make home visits. The Plan denied your
request. The Plan says the services were rendered by a non-network provider. The Plan also says that these
services were not 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 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 chronic care management services provided on January 18, 2021 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional transportation trips.You asked the Plan to provide coverage for additional transportation trips.The Plan denied your request. The Plan says the member has exhausted all of the transportation trips for this year.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 20 one-way 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 provide coverage for additional transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 12, 2021.
You asked the Plan to pay for foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedures provided on October 30, 2020, billed with codes 54360, 54405-AS, and 55175-AS.
You asked the Plan to pay for the surgical procedures. You say that this service was medically necessary and should be paid. The Plan denied your request. The Plan says there is no detailed procedure note to support payment.
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 the codes at issue are not supported. The records do not provide a detailed procedure note which describe the services performed. Based on this information, we decided that Medicare rules for coverage of the surgical procedures have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedures provided on October 30, 2020, billed with codes 54360, 54405-AS, and 55175-AS.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued stay at the skilled nursing facility (SNF) provided from January 23, 2021, to February 21, 2021.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled services on the dates of service in this case. The Plan also says that the enrollee does not meet the Medicare coverage guidelines.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the continued stay at the skilled nursing facility (SNF) provided from January 23, 2021, to February 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from December 28, 2020, to December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider from December 28, 2020, to December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water
and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan
says that you do not require intensive care coordination and you do not have a high risk for hospitalizations or
high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3346 and D7510).
You asked the Plan to pre-approve dental services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested dental services are not covered.
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 pre-approve dental services (D3346 and D7510).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on September 11, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim.
Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have had several toes amputated and this
affects your ability to walk. The Plan denied your request. The Plan says this item is not a covered benefit.
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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with single power option (K0837) with a power tilt seating system (E1002).
You asked the Plan to pre-approve the requested PWC with a power tilt seating system. You say that it is felt that the requested PWC meets the enrollees needs. The Plan denied your request. The Plan says the specific type of PWC being requested is not medically necessary because criteria for a power tilt seating system are not met.
The Plan follows Medicare rules. Medicare rules say that Group 2 PWCs with a single power option are only covered for enrollees when the criteria listed in the Medicare rules section are met.
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 requested PWC with a power tilt seating system. Our reviewer says that the requested single power option PWC is not considered medically reasonable and necessary as the enrollee does not require a power tilt seating system. Our physician reviewer found the beneficiary meets criteria for a power wheelchair; however, the documentation does not indicate that she requires a power tilt or power recline option. She is not at high risk for skin breakdown, does not use intermittent catheterization, and does not have increased tone or spasticity. Therefore, the Group 2 PWC that has been requested is not 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 requested PWC with a power tilt seating system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with single power option (K0837) with a power tilt seating system (E1002).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
November 4, 2020, through November 8, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says an inpatient admission was not medically necessary. The services provided could have been delivered in a short stay (observation) level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnight. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnight or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 67-year-old female with end stage renal disease who presented to the Emergency Department for emergency placement of a right arm arteriovenous graft for permanent dialysis. The procedure had been postponed due to anticoagulation therapy needing adjustment, so she was admitted on heparin. However, on assessment, labs suggested she did not require dialysis and so the procedure was discontinued. The enrollee was hemodynamically stable before and after admission and there was no indication that the enrollee would have required hospitalization that would likely have crossed two midnight based on the documentation 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 4, 2020, through November 8, 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 it not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on September 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the drug testing was performed in good faith and medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the drug testing provided on September 18, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve home health services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the services you are requesting.
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 home health services to be provided by an out of network (OON) provider.