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

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided September 18, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that the plan told you it was all cleared and the provider cleared it all with the plan before you would even have the surgery. You never would have had the surgery if it was not in network. The Plan denied your request. The Plan says the records indicate that the enrollee was prescribed this device for blood clot prevention. This item is not covered for this purpose.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on November 23, 2020.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were not aware that x-rays are not covered under your plan. The Plan denied your request. The Plan says this procedure is not a benefit under your dental plan.

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 complete series of intraoral x-rays are not among those covered under this benefit. The contract says that up to 4 films in a single visit of bitewing x-rays are the only covered x-rays under your plan. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on November 23, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMs device.

You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

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 a CardioMEMs device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found CardioMEMs pressure sensing device has been shown in clinical trials to improve symptoms of dyspnea, quality of life scores, heart failure class and reduce rehospitalization. Although ischemia continues to play a significant role in the overall disease burden in this enrollee, optimizing her filling pressures in the setting of mild CHF will likely aid in her ongoing care and outpatient management. She fits the reasonable published and FDA criteria for use of Cardiomems pressure sensor (depressed EF, on guideline directed therapy, Class III or greater symptoms, recent or recurrent hospitalization) and this meets the medical reasonableness and necessity criteria of the applicable CMS rule 1862(a).

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 CardioMEMs device have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMs device.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 1, 2020, to September 15, 2020.

You asked the Plan to waive the copayment for SNF care. You say that you feel you should not be held responsible for the copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care up to an in-network maximum out-of-pocket amount of $5,100 for 2020. At the time this claim was processed, $3,090.78 of the $5,100 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 14 days, which were days 29 to 42 of the benefit period, resulting in a total copayment amount of $2,009.22 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $5,100 in-network maximum out-of-pocket amount for 2020.

You have been asked to pay a $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 SNF care provided from September 1, 2020, to September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion or replacement of a peripheral or gastric neurostimulator pulse generator or receiver (64555, 64590).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan follows 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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that the enrollee has right shoulder pain from rotator cuff Arthropathy.

She has had trials of Gabapentin, Cymbalta, Ibuprofen and Tylenol for pain. The enrollee has had physical therapy, peripheral nerve blocks and intra-articular injections. She had a psychological evaluation which did not mention her forgetfulness, but cleared her for a peripheral nerve stimulator. She had a six week trial of a peripheral nerve stimulator. A peripheral nerve stimulator is not a substitution for a shoulder arthroplasty. The requested procedure is not indicated and is not medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion or replacement of a peripheral or gastric neurostimulator pulse generator or receiver (64555, 64590).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the current role of this treatment remains uncertain.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on August 11, 2020.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 99291 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture (D5120), a partial denture (D5211), and implant surgery (D6011).

You asked the Plan to pre-approve a complete denture (D5120), a partial denture (D5211), and implant surgery (D6011). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 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, dental code D6011 is not among those covered under this benefit. The Plan's contract also says that dental codes D5120 and D5211 are covered once every 5 years. The file shows that you received these services on March 20, 2020, which is less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a complete denture (D5120), a partial denture (D5211), and implant surgery (D6011).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided November 28, 2020.

You asked the Plan to waive the copayment for the inpatient services. You say that this should have been an observation stay. The Plan denied your request. The Plan says the correct cost share has been 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 $350 copayment per admission for each inpatient hospital stay.

You have been asked to pay $105.01 for the inpatient services. The inpatient services fall within the 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 inpatient hospital services provided November 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CGM supplies and accessories to be provided by the
out-of-network provider from May 16, 2021, through December 31, 2021.

You asked the Plan to pre-approve the CGM supplies and accessories. The Plan denied your request. The Plan
says the service is available in-network. There are no extenuating circumstances related to geographic access,
reasonable continuity of care, or unique medically recognized qualifications of the requested out-of-network
provider to justify prior authorization of out-of-network benefits beyond the transition of care.

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 at issue in this appeal. We found no exception that would require the Plan
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve CGM supplies
and accessories to be provided by the out-of-network provider from May 16, 2021, through December 31,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria for the
pneumatic compression device have not been met.

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 pre-approve a pneumatic compression device (E0652).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says this service is covered under your benefit package, but exceeds the maximum count allowed per period.

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 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a penial implant.

You asked the Plan to pre-approve a penial implant. You say that this implant is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare requires specific documentation for approval of this implant and surgery. Neither you nor your physician have provided medical records to show this surgery is appropriate. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pre-approve a penial implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).

You asked the Plan to pre-approve a maxillary partial denture. You say that you need the denture replacement.
The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the
frequency limit of one every five years.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a maxillary partial denture have not been met. Specifically, the record shows that you had
exceeded the frequency limit prior to this service on August 3, 2020. Therefore, we decided that the Plan does
not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost-share for occupational therapy services and hospital stays provided from April 1, 2020, through May 4, 2020, by an out-of-network provider.

You asked the Plan to reduce the cost-share for the medical services. You say that your maximum out-of-pocket is $6700 and your bills are far exceeding this total. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Page 57 of your 2020 Evidence of Coverage (EOC) shows you have a $500.00 out-of-network deductible, which you had not met when the Plan received the claim for April 1, 2020, through April 30, 2020, so $119.42 was applied towards your deductible. Page 57 of you EOC says your deductible "is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services." Skilled nursing facility care at an out-of-network facility for days 1-100 applies 50% coinsurance as member responsibility. As the claim for services on April 1, 2020, helped meet the deductible, the rest of the charges applied the 50% coinsurance of $3779.75 bringing the total member responsibility for this claim to $3899.17. The claim for services on May 1, 2020, through May 4, 2020, processed with 50% coinsurance as well with a total of $368.61. Page 58 of your EOC shows that you have a combined maximum out-of-pocket of $10,000. The $6700.00 out-of-pocket is for in-network services only. 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 reduce the cost-share for occupational therapy services and hospital stays provided from April 1, 2020, through May 4, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oximetry testing to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve oximetry. You say that this test has been approved in the past. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and your primary care provider has not indicated that this testing is medically necessary for you.

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 oximetry testing to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service with no transportation provided on June 30, 2020.

You asked the Plan to pay for ambulance no transport service. You say that the enrollee had a medical emergency but declined transportation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because ambulance service with no transport is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance service with no transportation provided on June 30, 2020.