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

We decided that the Plan does not have to pay for a continuous glucose monitor disposable sensor (HCPCS A9276).
You asked the Plan to pay for the sensor. You say that this should be paid for. The Plan denied your request. The Plan says this code cannot be billed separately.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code A9276 is not supported in the medical record. Specifically, this code cannot be coded separately. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor disposable sensor (HCPCS A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions of erupted tooth requiring removal of
bone and/or sectioning of tooth of tooth and four extractions of erupted tooth or exposed root of tooth provided
by an OON dentist on August 23, 2019.
You asked the Plan to pay for the extractions. You say that you did not know about the $2,000 yearly dental
benefit until after you paid for these 6 extractions. You also say that if you had known about this benefit, you
would have gone to an in-network provider. The Plan denied your request. The Plan says these services were
rendered by an out-of-network provider. The Plan also says that these services are only covered when they are
received from an in-network provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the
two extractions of erupted tooth requiring removal of bone and/or sectioning of tooth of tooth and four
extractions of erupted tooth or exposed root of tooth provided by an OON dentist on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exercise pulley (E1399).
You asked the Plan to pre-approve an exercise pulley. You say that you were recently operated on and you need the equipment for your therapy. The Plan denied your request. The Plan says this item is considered exercise equipment and is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an exercise pulley (E1399).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent planned transportation. You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergent planned transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for a knee replacement procedure.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights 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 pre-approve 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 the procedure can safely be performed in the outpatient setting. The record does not support the need for inpatient 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for a knee replacement procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation to be provided.
You asked the Plan to pre-approve routine transportation. You say that the enrollee needs transportation to complete the rest of his treatments. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not covered by the Plan.
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 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the enrollee has 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 to be provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat FoundationOne genomic testing.
You asked the Plan to pre-approve the testing. You say that this is needed to get FDA approval for a possible drug that can help you. The Plan denied your request. The Plan says this testing has already been received.
The Plan must follow Medicare rules. The rules say that repeat Genomic Sequential Analysis Panel testing is not covered. The file shows that this testing has already been received in your lifetime. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat FoundationOne genomic testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
You asked the Plan to pre-approve BRCA testing. You say that the enrollee has very limited information about her maternal family history and no information about her paternal family history. This means that her risk for hereditary cancer is unknown, so genetic testing is the only way to address this unknown risk. The Plan denied your request. The Plan says the denial of authorization for these tests is correct, because the enrollee has no family medical history of ovarian, prostate, pancreatic, or male breast cancer besides the enrollee's mother, and therefore does not meet Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 testing are only covered for individuals who meet certain specific criteria. 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 BRCA testing. Our reviewer says that the enrollee does not meet the Medicare criteria for coverage of these tests. Our physician reviewer found the enrollee was diagnosed with breast cancer at age 63 and her mother was diagnosed with breast cancer at age 73. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered to on September 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99285 is not supported.
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 99285 is Level 5 emergency department visit, problem with significant threat to life or function. We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation supports one unit of this code, which was previously paid by the Plan. There is no documentation to support additional billed services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered to on September 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from October 11, 2019, to December 17, 2019.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider from October 11, 2019, to December 17, 2019.
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 the records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee's condition is not at a level of complexity that requires an intensive and coordinated interdisciplinary approach, including physician visits at least three times weekly. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 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 enrollee was medically stable with no evidence of need for supervision by physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Continuous passive motion (CPM) exercise device for use other than knee (E0936).
You asked the Plan to pre-approve the CPM device. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says CPM devices are not covered by Medicare for the shoulder. This device is only covered after certain types of knee surgery.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve Continuous passive motion (CPM) exercise device for use other than knee (E0936).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the chest spine and lumbar spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that this is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee is greater than 50 years of age and has significant back pain. For these reasons alone he qualifies for the requested MRI scans per the plan's published criteria. That said, the enrollee more importantly has red flags consisting of lower extremity weakness and decreased deep tendon reflexes. Since the past medical history is not included in the records submitted it is impossible to determine how chronic these findings are. Since the patient has red flags as above the request for MRI of the thoracic and lumbar spine should be approved. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the chest spine and lumbar spine for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary, so that she can return to her pre-fall status. The Plan denied your request. The Plan says SNF care is not medically necessary because the enrollee does not require daily skilled services to be provided only on an inpatient basis in a SNF. The Plan says that the enrollee's needs can be met at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care or other SNF level skilled nursing need. The enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the pneumatic compression device. You say that the device is only available at this practice. The Plan denied your request. The Plan says there are network providers that can provide comparable DME. The item at issue is not emergent in nature. 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 a pneumatic compression device (E0651) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant or abutment supported fixed denture for edentulous arch (D6115).
You asked the Plan to pre-approve the dental service. You say that the enrollee was completely edentulous. You say that the enrollee has little to no mandibular ride to attach a denture. You say that due to this, the enrollee will need an implant supported denture. The Plan denied your request. The Plan says implant or abutment supported fixed denture for edentulous arch is not a covered service.
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 implant supported denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant or abutment supported fixed denture for edentulous arch (D6115).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 28, 2019 to November 8, 2019.
You asked the Plan to pay for home health 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 missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the provider is required to have the RAP claim to process and pay the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 28, 2019 to November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on October 31, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says documentation submitted did
not indicate the provider discussed the need for the billed supply codes.
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. The ordering physician notes do not mention, or support, the medical
necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee
orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does
not have to pay for the knee orthoses and suspension sleeves provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #5.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you received this service less than 60 months ago.
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, crowns may not be provided more often than once per tooth every 5 years. The record shows that you received a crown on tooth #5 on December 19, 2017 and your crowns benefit for tooth #5 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you would like to continue seeing the provider.The Plan denied your request. The Plan says there are in-network providers in your area who are available and able to treat your condition.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 the medical services to be provided by an out of network (OON) provider.