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

We decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960) provided October 2, 2020.

You asked the Plan to pay for the orthosis. You say that please review provided documentation and process the claim for payment as the enrollee is using the item and it is helping the them.The Plan denied your request. The Plan says the services are not documented in the enrollee's medical records.

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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay for Shoulder elbow wrist hand orthosis (L3960) provided October 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the CT scan provided on October 26, 2020.
You asked the Plan to waive the cost for the CT scan. You say that you were informed you were completely
covered for this procedure. You say that you should not have to pay this. 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 in-network deductible is $150. This is the amount you have to pay out-ofpocket
before the Plan will pay its share for your Medicare Part A and Part B covered services. Your contract
with the Plan also says that you must pay 4% of the cost for each Medicare-covered diagnostic radiology and
complex imaging service from an in-network provider.
The item or service you asked the Plan to waive the cost for falls within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing
in the contract that your $150 deductible applies to diagnostic tests. This cost sharing is a contractual obligation
that had not been met at the time the CT scan was received on October 26, 2020. Therefore, $92.04 has been
applied to meet your $150 deductible.
Since the $150 deductible was met you have also been asked to pay $0.63. The allowed amount is $15.73 (4%
x $15.73 = $0.63). 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 for the CT scan provided on October 26,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (97110) provided on August 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (97110) provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle control orthosis (L4350) provided on October 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ankle control orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the equipment provided was not urgent, emergent or 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 had network providers available who could have provided 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 ankle control orthosis (L4350) provided on October 19, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 13, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not advised that the treating provider is OON. The Plan denied your request. The Plan says this claim processed correctly according to your plan benefits.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 13, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair and walker provided on November 13, 2020.
You asked the Plan to pay for a shower chair and walker. You say that you would like reconsideration because you were informed that both of these items would be covered. The Plan denied your request. The Plan says there is no doctors order or prescription for the walker and shower chairs are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Additionally, the documentation submitted does not indicate that a physician ordered or prescribed the walker. Therefore, we decided that the Plan does not have to pay for a shower chair and walker provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom left-knee orthosis (L1846).

You asked the Plan to pre-approve a custom knee orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says insufficient information was provided to establish the enrollee's need for the requested item.

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 a custom knee orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has osteoarthritis and distant injury to left leg and knee. Medicare rules indicate that a custom fabricated orthosis is covered when there is a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. In this case, the medical records from the physician do not document the physical characteristics that indicate a custom orthosis is necessary. The elements of the coverage rule 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 a custom knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom left-knee orthosis (L1846).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) and Supply allowance for therapeutic continuous glucose monitor (CGM)(K0553) provided November 17, 2020.

You asked the Plan to pay for the monitor and supplies. You say that you have attached medical records for review in regards to the 11/17/2020 denial.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above.

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 monitor and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not support that the enrollee is insulin-treated with three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump, and the insulin treatment regimen requires frequent adjustment by the enrollee on the basis of BGM or CGM testing results

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 monitor and supplies have not been met.Therefore, we decided that the Plan does not have to pay for receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor 
system (K0554) and Supply allowance for therapeutic continuous glucose monitor (CGM)(K0553) provided November 17, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) services provided from August 3, 2020, to August 14, 2020, billed with code KAGD.
You asked the Plan to pay for SNF services billed with KAGD. You say that the billed HIPPS code is supported. The Plan denied your request. The Plan says that this should be billed with the authorized code KAKD.
The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF PDPM PPS. Under this system, each digit of the HIPPS code corresponds to a different case-mix group aspect of the SNF care provided. We looked at the file and Medicare rules. Based on the PDPM calculations worksheet and the conditions reported by the SNF, the billed HIPPS code is correct. The records document that the enrollee had chronic obstructive pulmonary disease with shortness of breath when lying flat, a nursing function score of 6-14, and no depression. Based on this information, we decided that Medicare rules for coverage of SNF services billed with KAGD have been met. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided from August 3, 2020, to August 14, 2020, billed with code KAGD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823).

You asked the Plan to pre-approve a Group 2 power wheelchair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of a Group 2 power wheelchair have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain relevant medical records which support medical necessity for the supplies requested in this case. Specifically, the record lacks a 7-element order, detailed cost list, and a functional assessment and home evaluation by a physical or occupational therapist. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 27134) provided on May 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 code 27134 is "Revision of total hip arthroplasty; both components, with or without autograft or allograft". 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 services. Our reviewer says that the use of CPT code 27134 is not supported by the records provided. Our physician reviewer found that the operative report does not include documentation of revision of acetabular component. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 27134) provided on May 19, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services (86316) provided to you on November 9, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this is not a covered service.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided the lab services by a contract provider. The file does not show that the Plan provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services (86316) provided to you on November 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical supplies (A9588) you received on February 11, 2020.
You asked the Plan to waive the coinsurance. You say that you should only be responsible for the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.
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 20% coinsurance for each Medicare-covered medical supply. Review of the file shows that you were provided medical supplies on February 11, 2020. You have been asked to pay a 20% coinsurance for the supplies, totaling $958.80. The supplies fall within the outpatient diagnostic tests 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 coinsurance for the medical supplies (A9588) you received on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two reductions of Osseous tuberosity (D7485 x2), first 15 minutes of deep sedation/general anesthesia (D9222), two subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x2), and therapeutic parenteral drugs (D9612).

You asked the Plan to pre-approve the reductions of Osseous tuberosity, deep sedation/general anesthesia services, and therapeutic parenteral drugs. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says these 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 two reductions of Osseous tuberosity (D7485 x2), first 15 minutes of deep sedation/general anesthesia (D9222), two subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x2), and therapeutic parenteral drugs (D9612).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml inj.

You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary for the enrollee. The Plan denied your request. The Plan says step therapy criteria has not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of both an oral and intravenous form of bisphosphonates (Alendronate, Risedronate, and Zoledronic acid) before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml inj.
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. You say that you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.

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 you are a 70-year-old female who was admitted to an acute care hospital. 
In this case, you do not require the intensity of services provided at an IRF. Specifically, you are not
shown to be able to currently perform fifteen hours per week of rehabilitative services with regular physician
evaluation. Your care needs can be met at a lower 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided a participating provider on November 18, 2020, to December 1, 2020.

You asked the Plan to waive the copayment for vision services. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $40 copayment for vision care. 

You have been asked to pay a $40 copayment for vision services. The total amount you are being asked to pay is $80 ($40 x 2 = $80). Vision services fall within the vision 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 vision services provided a participating provider on November 18, 2020, to December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.