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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a pneumatic compression device. You say that you are at a loss trying to figure out why the Plan rejected the patient's opportunity to get the device to control his lymphedema in the legs. You also say that the patient has been given support stockings with ineffective results over the years. The Plan denied your request. The Plan says there are 5 in-network providers within a reasonable distance from the enrollee's location that can provide these services or item. The Plan also says the enrollee can find a list of in-network providers in the Provider Directory.

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 a pneumatic compression device (E0651, E0667) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).

You asked the Plan to pre-approve a power scooter. You say that you need this because it is difficult to walk.
The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that a power mobility device is covered if the 
beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more 
mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home and the mobility limitation cannot be sufficiently and safely 
resolved by the use of an appropriately fitted cane, walker, or manual wheelchair. The rules also say that if any 
power mobility device is only for use outside the home, it will be denied as noncovered. 

We looked at the file and Medicare rules. The submitted medical records indicate that you are largely 
independent with MRADLs and the scooter at issue is being requested primarily for community use outside of 
the home. Based on this information, we decided that Medicare rules for coverage of a power scooter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for specialist services and coinsurance
for an injection provided on January 20, 2021, and March 3, 2021.

You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based the services provided and the Plan
contract agreement. The Qualified Independent Contractor partially overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct contract language. The Plan says that for March 3, 2021, there was only a
$45 copayment applied for procedure code 99213. No other codes were billed, and no other cost share was
applied for this date of service.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the
Plan clearly says that enrollees must pay $45 copayment for specialist physician services. You have been asked
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive
the cost share charged for specialist services and an injection provided on January 20, 2021, to March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental bone grafts and dental implants (21248, 21210) 
to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve dental bone grafts and dental implants. You say that these services are 
medically necessary. The Plan denied your request. The Plan says dental services are not covered when 
provided out-of-network. Additionally, these services are not covered under your dental benefits.

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 does not cover 
service provided OON. 

We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of dental bone grafts and dental implants have not been met.
Therefore, we decided that the Plan does not have to pre-approve dental bone grafts and dental implants 
(21248, 21210) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from May 19, 2021, to August 11, 2021.

You asked the Plan to waive the copayments for outpatient mental health care. You say that this is a financial hardship for you. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient mental health care. 

You received outpatient mental health care from May 19, 2021, to August 11, 2021, for a total of 8 visits. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 (copayment) x 8 (outpatient mental health care visits) = $280. 

You have been asked to pay the total copayment amount of $280 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care 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 copayments for outpatient mental health care provided from May 19, 2021, to August 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance ($227.70) charged for a Medicare Part B
drug provided on February 19, 2021.

You asked the Plan to waive this coinsurance. You say that you do not believe this cost share is correct. You
were told there would be not cost for this. The Plan denied your request. The Plan says that this cost share was
applied based on the claim submitted by your provider and the Plan contract agreement. The Qualified Independent Contractor (QIC) overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided
additional information. The Plan states the Medicare allowed amount for this Medicare Part B drug is $1138.50
and 20% of that cost is $227.70, which was the applied coinsurance.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. The contract with the Plan says you pay 20% coinsurance for Medicare Part B drugs.
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 20% coinsurance ($227.70) charged for a Medicare Part B injection provided on
February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says there has been no documented trial of conservative therapy demonstrating failed response to treatment with a PCD coded as E0650 or E0651 for 4 weeks which is required under the Medicare coverage criteria.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Provigil.

You asked the Plan to pre-approve Provigil. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Provigil.

Benefits for Provigil may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 medical record does not indicate that the enrollee require services that she is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended.

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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a spinal electrical osteogenesis stimulator (E0748)
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the service is covered if the criteria in the Medicare Rules section is met. 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 a spinal electrical osteogenesis stimulator. Our reviewer says that the service is medically necessary. Our physician reviewer found the record indicates that you are to undergo a multi-level cervical spine fusion from C4-C7 at the time the request was made for this service.; the fusion involves four vertebrae. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal electrical osteogenesis stimulator have been met. Therefore, we decided that the Plan has to pre-approve a spinal electrical osteogenesis stimulator (E0748)
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted with osteomyelitis from diabetic foot ulcer and required a surgical procedure. The record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor (A9276).
You asked the Plan to pre-approve a continuous glucose monitor sensor. You say that the item should be covered. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor sensor have not been met. Specifically, the requested CGM device accessory does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor (A9276).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on July 18, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on July 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for end-stage renal disease (ESRD) related services monthly (90960, 90961) provided on January 31, 2020 to March 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the ESRD related services. You say that this enrollee has been your patient since 09/16/2016 and you have never had any problems getting paid. Please reprocess the claim as this was done as medically necessary. 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 has network providers available who can provide 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 end-stage renal disease (ESRD) related services monthly (90960, 90961) provided on January 31, 2020 to March 31, 2020 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.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission.

Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hypoxemia and pleural effusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 

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.