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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a Medicare plan may restrict members to a network of providers as long as medically necessary covered care is accessible and available through this network. The rules say that the Plan must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on page 1-6 of the 2020 Evidence of Coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99337) received on March 20, 2019.You asked the Plan to pay fora domiciliary or rest home visit. You say that this claim was untimely due to a system glitch.The Plan denied your request. The Plan says rules for payment have not been met.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 a domiciliary or rest home visit was not filed until July 21, 2020. 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 fora domiciliary or rest home visit (99337) received on March 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvesurgical extractions to be provided by an oral surgeon.You asked the Planto pre-approvethe extractions. You say that this is medically necessary.The Plandenied your request. The Plansaysservices provided by an oral surgeon 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. The plan covers dental services when provided by a participating general dentist.The requested provider is not covered. Based on this information, we decided that the Plan's rules for coverage of the extractions have not been met.Therefore, we decided that the Plandoes not haveto pre-approvesurgical extractions to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services rendered on August 7, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim has not been processed by the primary insurance.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan confirmed on December 7, 2020,that they are not the primary insurance for the date of service at issue. The Plan has not received an Explanation of Benefits (EOB) from the primary insurance.As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe physician services rendered on August 7, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services can be obtained at a lower level of care.The Plan must follow Medicare rules. Therules 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 indenying 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 there are no complex nursing or rehabilitation needsnor does the enrollee require an intensive rehabilitation therapy 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. Specifically, the services can be obtained at a lower level of care. This means IRF is notreasonable or necessary.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea patient lift (bathroom or toilet) for the enrollee.You asked the Planto pre-approvethe lift. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a Medicare-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 medicalin 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 Plandoes not haveto pre-approvea patient lift (bathroom or toilet) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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 relevantMedicare 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 that the patient is currently undergoing treatment at an acute care hospital (ACH) for pressure sores in the setting of paraplegia. The enrollee is receiving wound care. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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-approvelong term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auricular Stimulation Therapy (CPT Code 64555) and Percutaneous Implantation of Neurostimulator Electrode Array; Peripheral Nerve (L8679).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The following devices are listed under the Food and Drug Administration (FDA) documents as electro-acupuncture devices used for stimulation of auricular acupuncture points (CPT code 64999) and as such are non-covered. Acupuncture for stimulation of auricular points is not a covered Medicare benefit. NeuroStim system/NSS, P-Stim, ANSiStim, E-Pulse Other current or future devices when used for the procedure Auricular Peripheral Nerve Stimulation or Electro-Acupuncture, would also be considered a non-covered service. The request for Auricular Peripheral Nerve Stimulation is denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Medicare Act. Therefore, we decided that the Plan does not have to pre-approve Auricular Stimulation Therapy (CPT Code 64555) and Percutaneous Implantation of Neurostimulator Electrode Array; Peripheral Nerve (L8679).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the service is medically necessary.The Plan denied your request. The Plan says the service requested in not medically necessary or reasonable.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 are no services at the LTACH that the patientrequires that are not already available and covered at the current facility.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. Specifically, services can be obtained at the enrollee's current level of care. This means the service requested in not medically necessary or reasonable.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia for the amputation of the femur (01232) provided on February 28, 2020.You asked the Plan to pay forthe anesthesia. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not support the service billed.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 01232 is anesthesia for open procedures involving upper two-thirds of femur; amputation.We find that CPT code 01232 is not supported in the record. Specifically, the record does not indicate that the anesthesia services were rendered for the amputation of the femur. The clinical information shows that the procedure was an above elbow amputation. There is a more appropriate CPT code for the services rendered.  Based on this information, we decided that Medicare rules for coverage of the anesthesia have not been met.Therefore, we decided that the Plan does not have to pay foranesthesia for the amputation of the femur (01232) provided on February 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture (D5110) and complete mandibular denture (D5120).You asked the Plan to pre-approvethe complete maxillary denture and complete mandibular denture. You say that your house burnt down, and you were not able to save your dentures.The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on October 4, 2019, and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture (D5110) and complete mandibular denture (D5120)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve3D rendering with a CT scan for the enrollee.You asked the Planto pre-approvethe 3D rendering. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 3D rendering. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is known to have a small renal cyst, for which follow-up imaging was recommended. While such imaging is reasonable, there is no evidence to explain why 3D rendering is currently medically necessary.  Baseline imaging (CPT 74178) should be completed first, with follow-up based onthe 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 3D rendering have not been met.Therefore, we decided that the Plandoes not haveto pre-approve3D rendering with a CT scan for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foran ultrasound duplex scan (93978) and a retroperitoneal ultrasound (76775) provided on February 13, 2020.You asked the Plan to waive the copayments foran ultrasound duplex scan and a retroperitoneal ultrasound. You say that you should be charged less and the Plan should pay more for these services.The Plan denied your request. The Plan says these services processed correctly.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 $110 copayment for each radiological diagnostic service, including ultrasounds. You have been asked to pay a $110 copayment for an ultrasound duplex scan and a $30.35 copayment fora retroperitoneal ultrasound. Although both of these services fall within the radiological diagnostic service benefit category, the allowed amount for a retroperitoneal ultrasound is $30.35. Because this is less than your contractual copayment, you are responsible for the full allowed amount for this service.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 copayments foran ultrasound duplex scan (93978) and a retroperitoneal ultrasound (76775) provided on February 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that the records provided support the need for SNF care.The Plandenied your request. The Plansaysthe requested SNF care 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 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found here are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveskilled nursing facility (SNF) services for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 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 requestedIRF 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 diarrhea and knee pain after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive 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-approveacute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran outpatient clinic visit provided on August 27, 2020 by an out of network (OON) provider.You asked the Plan to pay foran outpatient clinic visit. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained.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 foran outpatient clinic visit provided on August 27, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe clinic visit/encounter, all-inclusive (T1015) provided October 11, 2019, to October 23, 2019.You asked the Plan to pay forthe clinic visit/encounter, all-inclusive. You say that you would like this claim paid.The Plan denied your request. The Plan says this service is not covered under your supplemental dental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefitthat 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 pay forthe clinic visit/encounter, all-inclusive (T1015) provided October 11, 2019, to October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2740, D2950) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthese are not covered services.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 benefitin excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D2740, D2950) for the enrollee