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

We decided that the Plan does not have to pre-approve a power wheelchair and accessories 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 this is not medically necessary.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the nurse practitioner/physician medical progress notes reveal that the enrollee is able to use a walker for their mobility deficit. The notes do not reveal a detailed neuromuscular exam of the upper extremities or clear evidence that a manual wheelchair would not be sufficient to alleviate the mobility deficit. The requested wheelchair with multiple power options exceeds the enrollee's need. There is no evidence of a high risk for development of a pressure ulcer, utilization of intermittent catheterization for bladder management, or need for a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). The enrollee's strength in the upper extremities with current ability to use a walker and need for a wheelchair for independence in self-care ADLs should be sufficient to control any power options through their own switches.

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 a power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), harness for upgrade to expandable controller, including all fasteners, connectors, and mounting hardware, each (CPT code E2313), and power seating system, combination tilt and recline, with mechanical shear reduction (CPT code E1007), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the clinical documentation does not show that the enrollee meets medical necessity criteria for the requested power wheelchair components. The Plan states the physical therapy re-evaluation document dated June 16, 2021, shows that the enrollee requires stand by assistance for transferring from sit to stand and transferring from the bed to chair with verbal cutes. The Plan states the enrollee is able to ambulate 125-150 feet with a rolling walker, the document does not show any evidence of pressure ulcers. The Plan states the enrollee does not meet criteria for a combination power tilt and power recline seating system (E1007). The Plan states there is no history of dependence upon intermittent catherization for bladder management, use of a ventilator, increased muscle tone and spasticity or history of a current pressure ulcer and the clinical documentation does not show that the enrollee has two or more seating system motors, therefore, the medical necessity for the expandable harness (E2313) and electronic connection between the wheelchair controller (E2311) is not supported.

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 DME have not been met. The power-tilt and recline (CPT code E1007) is not covered because the enrollee does not have any medical conditions that would require power recline. Furthermore, the advanced electronics (CPT code(s): E2313 and E2311) are not covered because the enrollee is being given a free upgrade to a Group 3 power chair (CPT code K0861) with these components in the chair that the enrollee does not qualify for. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), harness for upgrade to expandable controller, including all fasteners, connectors, and mounting hardware, each (CPT code E2313), and power seating system, combination tilt and recline, with mechanical shear reduction (CPT code E1007), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the member would benefit from the admission. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.

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. The patient appears to be unstable requiring additional short term acute care services which can safely be received at the current acute care facility prior to additional weaning which had been successful until recently. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 LTACH services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on September 10, 2020.
You asked the plan to pay for this equipment. You say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be billed separately for the condition of deep vein thrombosis.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on September 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) set-up of portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on March 9, 2021, by an OON provider.
You asked the Plan to pay for the diagnostic services. You say that your services are treated as an emergency in the nursing home and home health setting as these facilities are required by CMS to treat potential fractures and other conditions within a 4-hour window. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 chest x-ray (71045) set-up of portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided on March 9, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services you received from February 1, 2021, to February 9, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you were not well enough to be discharged on the 21st day due to pneumonia. The Plan denied your request. The Plan says you were charged this copayment 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 $0 copayment per day for days 1-20 and a $167.50 copayment per day for days 21-58 for skilled nursing facility services. Records show that you were admitted to the skilled nursing facility on January 15, 2021, and were discharged on February 9, 2021, for a total of 25 days. You were charged a $0 copayment for days 1-20. You have been charged a $167.50 copayment per day for the remaining 5 days, for a total of $837.50. 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 skilled nursing facility services you received from February 1, 2021, to February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
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 enrollee appears to be currently unstable, requiring short-term additional acute care services to stabilize feeding and complete infection treatment which can be safely completed at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time would not provide a clinical advantage. Transfer to a lower level of care may be considered when the patient is more stable and when treatment has completed. 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had at your primary care provider's office on October 15, 2020.
You asked the Plan to waive the copayment for the ECG. You say that you have never had to pay a copayment for this service when it is part of your annual physical. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that an ECG is not part of your annual physical, so a separate copayment applies.
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 $5 copayment for Medicare-covered tests.
You have been asked to pay a $5 copayment for the ECG. The ECG falls within the Medicare-covered tests benefit category. Your Evidence of Coverage lists the services that are included in your annual physical exam. ECGs and other tests are not included as part of this exam, so that is why a separate copayment applies 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 copayment for the electrocardiogram (ECG) you had at your primary care provider's office on October 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4342, D2740, D3120).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says these procedures 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D4342, D2740, D3120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80299, 80307, 82542, 83789,
G0480) rendered by the out-of-network (OON) provider on February 17, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay
for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (80299,
80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and 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 for laboratory services provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient visit (G0463) provided on May 14, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a hospital outpatient visit. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a hospital outpatient visit (G0463) provided on May 14, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00811) provided on February 17, 2020.
You asked the Plan to pay for anesthesia services. You say that this was originally filed timely. The Plan denied your request. The Plan says this was filed more than a year after the date of service and more than a year after the original claim was denied.
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 anesthesia services was not filed until May 10, 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 anesthesia services (00811) provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 2, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 physician services provided to the enrollee on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implant (D6010 x 2), the guided tissue regeneration (D4266), a bone graft at the time of implant placement (D6104 x 2), and non-intravenous conscious sedation (D9248).
You asked the Plan to pre-approve the dental services. You say that these services are necessary to correct your receding dental bone loss. You say that a stable and improved dental structure is important to help you have dentures positioned into place. You also say that that having to go through these services are essential to improve your overall dental condition. The Plan denied your request. The Plan says the requested services are not listed as 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the implant (D6010 x 2), the guided tissue regeneration (D4266), a bone graft at the time of implant placement (D6104 x 2), and non-intravenous conscious sedation (D9248).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right knee genicular nerve block (CPT code 64454), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary for functional improvement and pain management. The Plan denied your request. The Plan says genicular nerve block for knee pain is considered investigational.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve block procedure remains experimental for the treatment of knee pain. More research is needed to show safety and efficacy of the procedure. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve right knee genicular nerve block (CPT code 64454), for the enrollee.