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

We decided that the Plan does not have to pay for physician's services provided on July 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this device is not covered by Medicare.

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).
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 it is felt that IRF care is necessary. The Plan denied your request. The Plan says a lower level of care would be sufficient.
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia. Medical problems are stable.
There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine physical visit you had on April 28, 2021.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee Schedule indicates that the services in question are non-covered. 

We looked at the file and Medicare rules. In this case, code 99387 is assigned a status indicator of "N" under the Physician Fee Schedule, which means that the requested services are not covered. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for the routine physical visit you had on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided February 25, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients for suspected or documented cardiovascular-respiratory disease. 

We looked at the file and Medicare rules. The service at issue is a cardiovascular risk assessment panel, which is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399.

You asked the Plan to pre-approve the compression stockings. You say that you require these stockings. The Plan denied your request. The Plan says you do not have a qualifying wound.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code E1399.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for insulin administered in an insulin pump provided on April 27, 2021.
You asked the Plan to waive the coinsurance for insulin administered in an insulin pump. You say that you disagree with how the claim is being processed. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 20% coinsurance for insulin administered in an insulin pump. You received insulin administered in an insulin pump on April 27, 2021. The total allowed amount is $636.62 and 20% of that is $127.32. You have been asked to pay the total coinsurance amount of $127.32 for insulin administered in an insulin pump. Insulin administered in an insulin pump falls within the diabetes self-management training, diabetic
services and supplies 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 insulin administered in an insulin pump provided on April 27, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions (D7210 x 3) provided on April 13, 2021.
You asked the Plan to pay more for the dental services. You say that you have an allowance of $1,000. You say that the statement you received from the provider says that you were charged $1,148. You say that your balance should be $148 but you paid the provider $448. The Plan denied your request. The Plan says there is a $1,000 combine allowance for supplemental dental services every year. The Plan also says that the allowance has been exhausted.
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 allowance has been exhausted. The record shows that the Plan paid $98 for dental services performed on April 1, 2021, and $902 for dental services performed on the date of service in this case. $98+$902=$1,000. Therefore, we decided that the Plan does not have to pay more for the extractions (D7210 x 3) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on October 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 pain management services provided on October 12, 2020 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 power mobility device (PMD)(K0823).
You asked the Plan to pre-approve a PMD. You say that you really need this mobility device. The Plan denied your request. The Plan says the request cannot be approved because there was insufficient information to ascertain the enrollee's need.
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. The file shows that there was no home evaluation, no physical therapy or occupational therapy evaluation to ascertain the enrollee's need. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve the power mobility device (PMD)(K0823).
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 inpatient services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation.

The enrollee's 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care, per day (99223) subsequent hospital
care, per day (99232) hospital discharge day management, 30 minutes or less (99238) provided February 19,
2021 to February 23, 2021.
You asked the Plan to pay for the hospital services. You say that you request the Plan to process the claim and
make the payment for the services rendered by the provider. The Plan denied your request. The Plan says the
services has exceeded the maximum allowable units per dates of service.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 1.
In this case, CPT codes 99231-99233 are per diem services and may be reported only once per day. Only one
hospital discharge day management service is payable per patient per hospital stay. The MUE for CPT code
99232, 99223 and 99238 is 1 per date of service. The MAI value for this code is 1 per date of service. You
billed 2 units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules
for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to
pay for initial hospital care, per day (99223) subsequent hospital care, per day (99232) hospital discharge day
management, 30 minutes or less (99238) provided February 19, 2021 to February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 12, 2020.
You asked the Plan to pay for an office visit. You say that the pandemic made it difficult to file claims timely. The Plan denied your request. The Plan says this was filed more than a year after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for an office visit was not filed until May 24, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on February 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care.
It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: 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 inpatient rehabilitation is necessary to help your current condition. The Plan denied your request. The Plan says the criteria for an IRF admission have not been met, and you can safely receive the services you need in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 3 power mobility device features (E2311 and
E1012).
You asked the Plan to pre-approve the power mobility device features. You say that the features should be
covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power
wheelchair, but not the electronic connection feature (E2311) or attendant control (E2331) are not covered.
The Plan must follow Medicare rules. Medicare rules say that he notes state that these are needed when 2 or
more actuators are being used. The electrical connection between the wheelchair controller and two or more
motors (E2311) cannot be covered. Although there are two requested power options on this wheelchair (power
elevating leg rets and power seat elevator), neither can be approved. As no power feature is medically
necessary, the electronic connection (E2311) cannot be approved.
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or
without variable speed programmability which allows the legrest to be raised and lowered independently of the
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with
the power tilt and/or recline controls. The approved features already include these controls, so the E1012
feature cannot be approved. We looked at the file and Medicare rules. Based on this information, we decided
that Medicare rules for coverage of the power mobility device features have not been met. Therefore, we
decided that the Plan does not have to pre-approve group 3 power mobility device features (E2311 and E1012).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you will be able to sit and transfer out of the tub. The Plan denied your request. The Plan says this item is 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. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary and does meet
Medicare coverage criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior therapy, which included work on balance and strengthening of the lower
extremities and the records do not demonstrate that the unique skills of a professional therapist are required to
safely and effectively provide treatment, that the services can be safely and effectively performed only by a
therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise
program. The requested services are not part of a maintenance program, are the specialized skill, knowledge
and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.