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

We decided that the Plan does not have to pay for a osteogenesis stimulator provided to the enrollee on March 11, 2020.

You asked the Plan to pay for the osteogenesis stimulator. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that the medical documentation needs to support that Medicare coverage have been met. The documentation does not indicate that the physician indicated the osteogenesis stimulator, or that criteria were met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a osteogenesis stimulator provided to the enrollee on March 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you would like approval to see this out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 5, 2021, to March 8, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the last time you were never admitted. You say that since this was inpatient your copayment is way higher. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-5 for inpatient hospital care/in-network. 

You have been asked to pay a $300 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $900 ($300 x 3 days = $900). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on March 5, 2021, to March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
You asked the Plan to pre-approve periodontal scaling and root planing. You say that the service is medically necessary. The Plan denied your request. The Plan says this service was requested the same day D1110 was covered and therefore the Plan was unable to provide coverage on the same day.
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 periodontal scaling and root planing once per quadrant every 3 calendars years. This service is not allowed on the same date as D1110 or D1120. We looked at the the file and Medicare rules. Theis service was requested on the same date that the Plan covered a dental cleaning (D1110). Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing were not met at the time of the request. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341). If the enrollee still requires periodontal scaling and root planing, you may wish to submit a new request for coverage the service to be performed at a later date.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift provided on September 2, 2020 by a non-certified provider.

You asked the Plan to pay for the seat lift. You say that you needed to use this provider, there were no others. The Plan denied your request. The Plan says the provider is not certified with Medicare.

Medicare rules say that plans can require enrollees to get care from network providers. To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. A provider must be eligible to participate in Medicare to receive payment. Except for emergency services, the plan cannot pay a provider who is not eligible to participate in Medicare. The plan has confirmed that the provider Brick Street Furniture is not eligible for Medicare. 

The requested provider in this case is not a certified provider with Medicare. 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 a seat lift provided on September 2, 2020 by a non-certified provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for specialist services and coinsurance for an injection provided by a participating provider on March 12, 2021.

You asked the Plan to waive the co-payment for specialist services and coinsurance for an injection. You say that you feel like this should be covered in full. The Plan denied your request. The Plan says the correct charges have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment and a 20% coinsurance for physician/practitioner services/specialist and Medicare Part B prescription drugs.

You have been asked to pay a $30 co-payment for specialist services and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $54. The total amount for an injection is $10.40 ($54 x 20% = $10.40). The total amount you are being asked to pay is $40.40 ($30 + $10.40 = $40.40). Specialist services falls within the physician/practitioner services/specialist benefit category and an injection falls within the Medicare Part B prescription drugs 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 co-payment for specialist services and coinsurance for an injection provided by a participating provider on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing, 1 to 3 teeth per quadrant, (D4342) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you have gum disease. You say that you do not understand why this preventive procedure is not covered. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says periodontal scaling and root planing 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 periodontal scaling and root planing for all 4 quadrants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing, 1 to 3 teeth per quadrant, (D4342) for all 4 quadrants.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on July 6, 2020, to July 28, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that this should not cost you extra. The Plan denied your request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for outpatient rehabilitation services. 

You have been asked to pay a $15 copayment for physical therapy. The total amount you are being asked to pay is $90 ($15 x 6 visits = $90). Physical therapy falls within the outpatient rehabilitation services 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 physical therapy provided a participating provider on July 6, 2020, to July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. 

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 (E0675).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure represented by code 15004 provided on April 22, 2020.
You asked the Plan to pay for code 15004. You say that the medical records support the billing of CPT code 15004 provided on April 22, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 15004 provided on April 22, 2020.
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 15004 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.
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 pay for code 15004. Our reviewer says that the medical records do not support the billing of CPT code 15004 provided on April 22, 2020. Our physician reviewer found the enrollee underwent a surgical procedure. The operative note submitted does not indicate that an open wound, burn eschar, or scar was excised or that a scar contracture was released by incision. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 15004 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedure represented by code 15004 provided on April 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary The Plan denied your request. The Plan says coverage criteria has not been met.
The monitor is not being requested for therapeutic use.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued usage of the Optune device (E0766) for the enrollee.You asked the Plan to pre-approve continued usage of the Optune device. You say that that the enrollee meets criteria for coverage of the Optune device.The Plan denied your request. The Plan says that your request is not medically necessary because your records show you are not using the Optune device an average of 18 hours per day (or at least 75% of the time).The Plan must follow Medicare rules. Medicare rules say that continued coverage of TTFT beyond the first three months of therapy requires objective evidence of adherence to therapy. We looked at the file and Medicare rules. The usage report provided indicates the enrollee has not adhered to therapy the required 18 hours per day. Based on this information, we decided that Medicare rules for coverage of continued usage of the Optune device have not been met.Therefore, we decided that the Plan does not have to pre-approve continued usage of the Optune device (E0766) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prolotherapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve prolotherapy. You say that you strongly feel you should be allowed to have this treatment covered in order to give this option it's full benefit. It has been proven and said to be the best possible and highly effective option for the ailment you have. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. Medicare rules say that items and services that are not medically necessary are not covered. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve prolotherapy to be provided by an out of network (OON) provider.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that given the enrollee's age she would be safer in a rehabilitation facility from a medical point of view. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for scheduled T9-L1 fusion. The enrollee's medical conditions are stable. 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental item. You say that you got sick, and your dentures fell in the toilet. You also say that as you flushed it, the dentures went down too. The Plan denied your request. The Plan says dentures are limited to once every 5 years. The Plan also says that the frequency limit for this item has been reached.
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 and dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on April 5, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve holders for FreeStyle Libre continuous glucose monitor (CGM) sensor.
You asked the Plan to pre-approve holders for CGM sensor. You say that the supplier is supposed to send the enrollee a supply on the 22nd but you don't have enough sensor holders until then. You need two and you are wondering why this is happening. The Plan denied your request. The Plan says a holder for a CGM sensor is not covered as durable medical equipment because it is not primarily and customarily used to serve a medical purpose and is not considered reasonable and medically necessary.
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 medical in 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 Plan does not have to pre-approve holders for FreeStyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided by a participating provider on November 6, 2020.

You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you did not have a surgery. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient hospital services/an outpatient surgery. 

You have been asked to pay a $295 copayment for a hospital outpatient clinic visit. The correct copayment has been applied to the services that were provided. A hospital outpatient clinic visit fall within the outpatient hospital services/an outpatient surgery 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 a hospital outpatient clinic visit provided by a participating provider on November 6, 2020.