Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile radiology transportation fee for services provided.

You asked the Plan to pay for the mobile radiology transportation fee. You say that this was correctly billed and should be paid. The Plan denied your request. The Plan says this was billed with an inpatient POS code so the transportation fee is not separately payable as billed.

The Plan must follow Medicare rules. Medicare rules say that POS code 31 is used to report a patient in a Medicare Part A-covered SNF stay. Separate payment cannot be made for transportation of mobile radiology equipment for enrollees in a Part A stay.

In this case, the services billed are not payable in the POS 31 as these would be included in the payment to the SNF. Therefore, we decided that the Plan does not have to pay for the mobile radiology transportation fee for services provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from enrollee from April 2, 2021, forward.
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no skilled nursing needs until the enrollee developed a urinary tract infection (UTI) and required daily intravenous (IV) antibiotics. The enrollee remained hemodynamically and medically stable. As of April 2, 2021, the enrollee did not require any skilled nursing or rehab services on a daily basis on an inpatient level of care. The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of April 2, 2021.
The enrollee did not have any complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however their function had plateaued by April 2, 2021, and they did not require any further inpatient skilled rehab services. The enrollee's function was at or near their prior level of function and the enrollee could be discharged to a lower level of care for further services. Although the enrollee was prescribed daily antibiotics, this treatment could be provided at a lower level of care with home health services. As of April 2, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from enrollee from April 2, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0835).
You asked the Plan to pre-approve the group 2 power wheelchair. You say that the power chair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 2 power wheelchair. Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer found the documentation is not clear that the patient is able to safely maneuver the requested device around her home. The enrollee does not use intermittent catheterization or need a Group 2 power wheelchair for spasticity management. She is able to perform functional weight shifts and is not at high risk for developing a pressure ulcer. 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 group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0835).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve massage therapy. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says massage therapy is not covered.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplies for a non-therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says there is no benefit for supplies that are not classified as durable medical equipment.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM will be denied as non-covered We looked at the file and Medicare rules. The requested items are used with a non-therapeutic continuous glucose monitor. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies for a non-therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for the continued care being requested. The Plan denied your request. The Plan says the criteria for a continued stay have not been met. The Plan says that any needed services can be met at a lower level of care.
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. Our physician reviewer found There is no documentation provided necessitating admission to a LTACH. 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. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306).
You asked the Plan to pre-approve a transthoracic echocardiography (93306). You say that the requested transthoracic echocardiography (93306) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested transthoracic echocardiography (93306).
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 transthoracic echocardiography (93306). Our reviewer says that the enrollee does not meet criteria for the requested transthoracic echocardiography (93306). Our physician reviewer found the enrollee has no symptoms of congestive heart
failure (CHF) and no signs of CHF can be evaluated as this was a telemedicine visit. The reported recent echocardiogram findings showed normal LV function with no reported significant valvular heart disease. Based on the recent history and in the absence of any clinical changes (signs or symptoms) the enrollee would not meet any of the CMS LCD criteria for repeat echocardiography especially given the recent reported echocardiogram study findings which showed normal LV systolic function and only a mild diastolic abnormality. 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 transthoracic echocardiography (93306) have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that you need SNF care. The Plan denied your request. The Plan says SNF care is no longer medically necessary.
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 pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral evaluation (D0150) and tooth extraction
(D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve dental care to be provided by an oral surgeon. You say that you were
advised to see an oral surgeon for the requested extraction services due to other medical conditions. The Plan
denied your request. The Plan says your supplemental dental benefit covers one simple extraction or surgical
tooth removal procedure per year, but it must be performed by a participating general dentist.
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, services provided by anyone other than
a general dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pre-approve an oral evaluation (D0150) and tooth extraction (D7210) to be provided by an oral
surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that this request is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary as medical necessity criteria have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Synvisc. Our reviewer says that the request is not medically necessary and reasonable. Our physician reviewer found there is no documentation of any trial of conservative therapy prior to the initiation of viscosupplementation therapy. The review has determined that the documentation does not support that the requested Synvisc is medically reasonable or necessary for the patient. The documentation does not support that the requested Synvisc is safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve diabetic shoes and inserts. You say that you need diabetic shoes to help prevent you from hurting your foot. The Plan denied your request. The Plan says that there is no medical need showing why you cannot get these items from a network provider.
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 diabetic shoes and inserts to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compressor and pneumatic appliance to be provided by an out of network provider.
You asked the Plan to pre-approve the pneumatic compressor and pneumatic appliance. The Plan denied your request. The Plan says there is an in-network supplier available to provide this equipment.
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 pneumatic compressor and pneumatic appliance to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system (L5828, L5845, L5856, L5848), flex-walk system (L5981), and multi-axial rotation unit (L5986).
You asked the Plan to pre-approve an endoskeletal knee-shin system, flex-walk system, and multi-axial rotation unit. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not medically necessary and reasonable.
The Plan follows Medicare rules. Medicare rules say that these items require the enrollee to currently or is expected to be a level K3 ambulator. 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 an endoskeletal knee-shin system, flex-walk system, and multi-axial rotation unit. Our reviewer says that the request for endoskeletal knee-shin system (L5828, L5845, L5856, L5848), flex-walk system (L5981), and multi-axial rotation unit (L5986) is not medically necessary as the request exceeds the patient's medical need. Our physician reviewer found the physician documentation with multiple comorbidities including chronic back pain, notation of reduced endurance and November 11, 2020 documentation of expected ambulatory aid of a cane does not support that this patient is at least currently or expected to be a level K3 ambulator which these prosthetic devices require. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an endoskeletal knee-shin system, flex-walk system, and multi-axial rotation unit have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal knee-shin system (L5828, L5845, L5856, L5848), flex-walk system (L5981), and multi-axial rotation unit (L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transition lenses.
You asked the Plan to pre-approve transition lenses. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says transition lenses are not covered by Medicare or the Plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. The Plan contract offers a $400 vision allowance for routine contact
lenses or eyewear every year. Eyewear coverage does not include transition lenses. Based on this information,
we decided that the Plan's rules for coverage of transition lenses have not been met. Therefore, we decided that
the Plan does not have to pre-approve transition lenses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140), intraoral (periapical, single image) x-ray (D0220), and the service to re-cement or re-bond a crown (D2920) provided on June 10, 2020.
You asked the Plan to pay for the dental services. You say that you have supplemental coverage and cannot understand why these services are not covered. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's mandatory or additional optional supplemental dental 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, the requested items or services are not among those covered under either the mandatory or additional supplemental benefits. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140), intraoral (periapical, single image) x-ray (D0220), and the service to re-cement or re-bond a crown (D2920) provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral (complete series, full mouth) x-ray images (D0210) provided on October 26, 2020.
You asked the Plan to pay for the intraoral x-rays. You say that you cannot afford to pay this bill and you had called the Plan prior to services to make sure this provider was in the Plan's network and would be covered. The Plan denied your request. The Plan says this provider is in network; however, the intraoral (full mouth) x-rays are only covered by the Plan once every three years. The Plan paid for a full mouth x-ray in February of 2019, which is less than three years before the date of service in question. Therefore, the x-rays provided on October 26, 2020 cannot be covered as the Plan only covers full mouth x-rays once every three 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered more than once in a three-year period. The record shows that you received this service less than three years ago. Therefore, we decided that the Plan does not have to pay for intraoral (complete series, full mouth) x-ray images (D0210) provided on October 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on October 17, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the billed service, 70544, was denied because two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an issue with the diagnosis codes reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on October 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided by a participating provider on September 16, 2020.
You asked the Plan to waive the copayment for physician services. You say that you do not understand why you are being charged twice. 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 $50 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $50 copayment for physician services. When an outpatient surgery occurs, cost sharing amounts may apply to the physician services; therefore, the correct copayment has been applied. Physician services falls within the physician/practitioner services/in-network/specialist 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 physician services provided by a participating provider on September 16, 2020.