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

We decided that the Plan does not have to pre-approve power operated vehicle (POV) (K0800).

You asked the Plan to pre-approve POV. You say that the item is medically necessary. The Plan denied your request. The Plan says your home is not suited for the use of a POV, as there is not enough room to maneuver. The ability to complete activities of daily living such as bathing, toileting, and dressing will not be improved by use of a POV.

The Plan follows Medicare rules. Medicare rules say that a POV will not be covered if the patient's home does not provide adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided or if the use of a POV will not significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home.

The file shows that your home does not have the space required for a POV and that it will not improve daily living activities. 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 power operated vehicle (POV) (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoskeletal system below knee alignable system for a preparatory lower limb prosthesis.

You asked the Plan to pre-approve alignable system. You say that you need the same system on your left leg as your right leg in order to walk safely. The Plan denied your request. The Plan says the denial of authorization for this component is correct, because an alignable system is not needed for a preparatory prosthesis.

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 alignable system. Our reviewer says that you do not meet the Medicare criteria for the requested prosthetic component. Our physician reviewer found a conventional lower limb prosthetic device generally consists of a socket, suspension mechanism, knee joint, pylon, and terminal device. The documentation does not support that an endoskeletal system below knee alignable system is reasonable and necessary in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal system below knee alignable system for a preparatory lower limb prosthesis.
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 service is medically necessary. The Plan denied your request. The Plan says benefits can be provided 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 the short-term acute care hospital can provide for all of the patient's present inpatient care needs and the patient is receiving an appropriate level of care in the present 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 LTACH services have not been met. Specifically, the member can receive services at a lower level of care. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued coverage of CPAP for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is denied due to lack of use of the device.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has been non-compliant with CPAP therapy because of issues with obtaining new parts for the machine, including a mask that does not aggravate his facial pain. According to the physician's appeal letter, those issues have been addressed and the enrollee is now using the device. It is considered reasonable and medically necessary to provide another opportunity for the enrollee to meet the minimum usage requirement of at least four hours per day for at least 70% of days over at least a 30 day period.

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 been met. Therefore, we decided that the Plan has to pre-approve continued coverage of CPAP for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care.

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 the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 critical care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc-One drug injection (J7325).

You asked the Plan to waive the coinsurance for the drug injection. You say that you only had the drug injection service, and do not understand the bill amount. The Plan denied your request. The Plan says Medicare Part B drug services have a 20% coinsurance.

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 Medicare Part B prescription drugs.

You have been asked to pay $98.11 for the drug injection. The Plan's allowed amount for this service is $490.56 ($490.56 x 20% = $98.11). A Synvisc-One injection falls within the Medicare Part B prescription drugs benefit category. The record provided shows that you paid the correct $20 copayment for your office visit with a specialist at the time of service and were billed the amount for the drug separately. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Synvisc-One drug injection (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the denture
adjustment (D5741).

You asked the Plan to pay for the dental services. You say that the services were denied because you went to an
out of network provider. You say that you did a search online to see if the provider was in network. You also
say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case
is out of network. The Plan also says that dental services that you receive out of network are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of
network are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral
evaluation (D0140) and the denture adjustment (D5741).
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says that 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 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 that the enrollee was admitted with COVID 19 pneumonia. Her hospital stay has been significant for cardiopulmonary arrest requiring intubation, pneumonitis, hypoxemic respiratory failure, encephalopathy, distal trachea perforation, and a urinary tract infection. A Tracheostomy and a PEG tube have been placed. She remains on ventilator. It is documented that she had worsening leukocytosis and a fever as well as a drop in hemoglobin requiring transfusion. There is no documentation that the enrollee is capable of being weaned at this time.

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: 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 medical records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiology services (CPT 78598, CPT 93923) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requests were sent with the wrong billing codes.

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is reportedly suspected of having thromboembolic disease with deep venous thrombosis (DVT) and pulmonary embolism. The appropriate diagnostic studies are leg venous Doppler examinations, 93970, and pulmonary ventilation/perfusion (V/Q) scan, 78582. The requested codes are incorrect, and are considered not medically necessary. 78598 is for a quantitative V/Q scan, which is normally done to assess regional lung function prior to lung resection. 93923 is a study of the arterial circulation of the legs, and is not relevant to venous thrombosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiology services (CPT 78598, CPT 93923) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit.

You asked the Plan to waive the copayment for the podiatry visit. You say that diabetic foot care is a part of
your primary care and it is routine care. You say diabetic foot care is not specialty care. The Plan denied your
request. The Plan says you have been charged the correct cost sharing 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 a $40
copayment for each in-network Medicare-covered visit.

You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry
services" benefit category. The record shows the provider is a podiatrist and is considered a specialist. 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 the podiatry visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the unspecified preventive service (D1999).

You asked the Plan to pay the in network rate for the unspecified preventive service. You say that you did not ever receive notice that the doctor was no longer in network. You also say that you do not feel that you should be responsible to pay this bill since you were not informed. The Plan denied your request. The Plan says unspecified preventive service is not listed as 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the unspecified preventive service (D1999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crutch substitute, lower leg platform, w/wo wheels (E0118).

You asked the Plan to pre-approve crutch substitute, lower leg platform, w/wo wheels. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

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 crutch substitute, lower leg platform, w/wo wheels. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare says that Crutch Substitutes such as Knee Walkers have not been proven to be safe and effective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of crutch substitute, lower leg platform, w/wo wheels have not been met. Specifically, the item requested has not been proven to be safe or effective, and therefore, is not medically necessary or reasonable for this member. Therefore, we decided that the Plan does not have to pre-approve crutch substitute, lower leg platform, w/wo wheels (E0118).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy services (31638, 31636) provided by an out of network (OON) provider.

You asked the Plan to pay for the bronchoscopy services. You say that this was a medically necessary procedure that followed previous medical care. The Plan denied your request. The Plan says out of network services are not covered unless they are pre-approved, urgent or emergent, or when no in-network providers are available. None of these situations apply here. There were several weeks between the initial care and the follow up where a prior authorization could have been requested.

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, nor did they have a request for prior authorization on file. 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 the bronchoscopy services (31638, 31636) provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider.

You asked the Plan to waive the copayment for lab work. You say that you have to get this lab work every 6 months. You say that you think this copayment should be waived. The Plan denied your request. The Plan says you do not agree with this copayment.

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 $10 copayment for outpatient diagnostic tests/laboratory tests.

You have been asked to pay a $10 copayment for lab work. The correct copayment has been applied to the lab work that was provided. Lab work falls within the outpatient diagnostic tests/laboratory tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab work provided by a participating provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital services.

You asked the Plan to reduce the copayment for the hospital care. You say that you were admitted to the emergency department. You say that your doctor offered to keep you as an inpatient, but you declined and did not stay overnight in a room. You say that you want to pay your $90 copayment for emergency care rather than the $325 copayment for inpatient care. The Plan denied your request. The Plan says you were billed correctly as an inpatient. Inpatient care has a $325 copay for each of the first 5 days of an admission.

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 $325 copayment for each of the first five days of an inpatient stay.

You have been asked to pay a $325 copayment for the hospital care. Medical records were provided to show that you were admitted as an inpatient and received inpatient services outside of emergency care. You were discharged and have been asked to pay for one day of inpatient services. 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 reduce the copayment for the inpatient hospital services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy provided by an out of network provider.

You asked the Plan to pay for the colonoscopy. You say that the enrollee gave the wrong health insurance information. The Plan denied your request. The Plan says you did not request prior authorization.

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 the colonoscopy provided by an out of network provider.