Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires daily skilled care due to his condition. The Plan denied your request. The Plan says the enrollee is not requiring daily skilled services at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital after a fall resulting in a femur fracture near the prosthetic hip joint. He required open reduction and internal fixation (ORIF) on 1/3/2022, and is now non-weightbearing, though he has been non-ambulatory for over a year. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is bedbound at baseline and is currently limited by his weight-bearing status. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from June 12, 2021, to June 28, 2021.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you would like the services to be reprocessed as inpatient. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services. The medical records show that the enrollee received outpatient rehabilitation services from June 12, 2021, to June 28, 2021, for a total 15 days. Therefore, the enrollee is responsible to pay a $40 copayment per each visit.
The total amount they owe is: $40 (copayment) x 15 (outpatient rehabilitation services) = $600. The enrollee has been asked to pay the total copayment amount of $600 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that the enrollee has 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 copayments for outpatient rehabilitation services provided from June 12, 2021, to June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 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 there is no qualifying diagnosis causing a mobility limitation for which K0862 is medically needed.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. 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 based on the medical records provided, there is no documentation of a qualifying diagnosis for a group 3 power wheelchair. The enrollee does not have a diagnosis of a neurological disease, myopathy or congenital skeletal deformity which meets Medicare criteria for coverage of a group 3 power wheelchair. The records indicate that the enrollee's mobility limitation is the result of morbid obesity, chronic kidney disease, heart disease, asthma and lymphedema. 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 group 3 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on June 25, 2021.
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 procedure code 00520 is not supported.
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 00520 is anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified. We find that CPT code 00520 is not supported in the medical record. Specifically, the records show that the anesthesia services is inconsistent with the billed surgical procedure, debridement of subcutaneous tissue. There is no documentation of a closed chest procedure for which anesthesia was performed. 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 anesthesia services rendered on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for a computed tomography (CT) scan.
You asked the Plan to adjust the copayment for a CT scan. You say that you need this CT scan but the copayment is too much money and you cannot afford it. The Plan denied your request. The Plan says the copayment amount cannot be adjusted.
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 $250 copayment for outpatient diagnostic testing. You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient diagnostic testing 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 adjust the copayment for a computed tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a telephone medical alert system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily 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 a telephone medical alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sterile gloves, per pair (A4930).
You asked the Plan to pre-approve the sterile gloves. You say that the gloves are medically necessary and required for sanitary reasons and prevention of infectious disease. The Plan denied your request. The Plan says disposable gloves are not considered durable medical equipment and not listed as a supplemental benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily 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 sterile gloves, per pair (A4930).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 physical therapy (PT) visits.
You asked the Plan to pre-approve 24 PT visits. 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 Medicare pays for medically necessary outpatient therapy. 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 24 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and
effective therapy for your condition beyond what was approved by the health plan. You have extensive approved therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist beyond the additional therapy approved by the health plan. You have been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 24 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 physical therapy (PT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, laboratory services, and physical therapy rendered on April 28, 2021 to June 19, 2021.
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 services received outside of the United States are not covered.
The Plan must follow Medicare rules. The rules say that Medicare generally does not cover items and services furnished outside of the United States. We looked at the file and Medicare rules. The file shows that you received an office visit, laboratory services, and physical therapy related to a known diagnosis of vertigo. The services were not for an emergency and were performed outside of the United States. 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 office visit, laboratory services, and physical therapy rendered on April 28, 2021 to June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits with routine labs and x-rays to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visits with routine labs and x-rays. You say that the enrollee states she was given incorrect information that the provider is in-network. The Plan denied your request. The Plan says the provider is out-of-network
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 the office visits with routine labs and x-rays to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a round-trip, non-emergency transportation by taxi between home and physician office.
You asked the Plan to pre-approve a round-trip, non-emergency transportation by taxi between home and physician office. The Plan denied your request. The Plan says the only mode of transportation Medicare covers is ambulance transportation, and then only when an ambulance is medically necessary. Medicare does not cover non-emergency transportation. Based on the information received, the requested transportation is by taxi between your home and physician's office, not one-way by wheelchair van or chair car from a hospital or to a SNF.
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation is only covered when the supplier meets the applicable vehicle, staff, and billing and reporting requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of taxi service have not been met. Specifically, the Medicare transportation benefit is limited to transportation by a fully equipped ambulance with appropriately trained staff. The file shows that the transportation requested is with a taxi. This means that the service at issue is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a round-trip, non-emergency transportation by taxi between home and physician office.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667), to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a pneumatic compression device and segmental pneumatic appliance. You say that the items are medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services to be obtained out-of-network.
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 (E0652) and segmental pneumatic appliance (E0667), to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation (D9222, D9223 x 3).
You asked the Plan to pre-approve the dental services. You say that you need the deep sedation services. You say that you are getting 7 teeth extracted. You also say that you have severe anxiety. The Plan denied your request. The Plan says deep sedation services are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested deep sedation services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep sedation (D9222, D9223 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve the repeat ESI. You say that you need this procedure to help with your spinal pain. The Plan denied your request. The Plan says you did not receive sufficient pain relief from your previous ESI to support the medical necessity of this procedure.
The Plan follows Medicare rules. Medicare rules say that repeat ESIs are considered reasonable and necessary when a prior ESI produced 50% pain relief for at least three months. 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 repeat ESI. Our reviewer says that the documentation does not support the medical necessity of the requested injection. Our physician reviewer found the enrollee has a history of back pain with radiculopathy. She underwent an ESI in December 2020 that provided 50% pain relief for two months. There is no documentation that the enrollee received at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using same scale for at least three (3) months. The review has determined that the enrollee does not meet the coverage criteria for the requested repeat of a transforaminal epidural steroid injection. 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 repeat ESI have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection (ESI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair and related accessories to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and related accessories 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 compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you need a submandibular compression garment. This is medically necessary to minimize the risk of infection and to manage swallowing more effectively as well as to decrease pain. The Plan denied your request. The Plan says this item is not a covered benefit. Compression garments for the chest, labia, trunk or neck are experimental and investigational.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
You asked the Plan to pre-approve 6 home health physical therapy visits. 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 Medicare pays for medically necessary outpatient
therapy.
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 6 home health physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the enrollee does not have documented,
ongoing; home health physical therapy needs. The enrollee is ambulating more than 100 feet, functioning with
modified independence and residing with an available caregiver. The enrollee's therapy needs can be met at a
lower level of care. As such, the requested, ongoing, home health physical therapy is not medically necessary
or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 6 home health physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 6 home health physical therapy visits
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laparoscopy provided on May 3, 2021.
You asked the Plan to waive the copayment for the laparoscopy. You say that a few doctors are asking for a $50 copayment for the same thing. You say that one was denied, and you are still being charged $50. The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for each Medicare- covered specialist office visit. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location.
You have been asked to pay a $50 copayment for the laparoscopy. The laparoscopy falls within the
"Physician/Practitioner services, including doctor's office visits" 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 the laparoscopy provided on May 3, 2021.