Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided to the enrollee on July 7, 2021.

You asked the Plan to pay for the services. You say that the service was rendered due to medical necessary and patient care was provided at an urgent request. The Plan denied your request. The Plan says there was no authorization for the 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 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 wound care services provided to the enrollee on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rebase complete maxillary denture (D5710) and rebase complete mandibular denture (D5711).
You asked the Plan to pre-approve a rebase complete upper and lower denture. You say that you would like these services covered. The Plan denied your request. The Plan says these services are not covered under your 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. 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 a rebase complete maxillary denture (D5710) and rebase complete mandibular denture (D5711).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553) provided on July 10, 2021.
You asked the Plan to pay for the continuous glucose monitor supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says documentation submitted did not sufficiently support the signed written order for the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication in the medical records submitted that the member's physician discussed the need for the billed supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor supplies (K0553) provided on July 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the impact guards and hub (K0108), propulsion wheel (E2224), hamdrim (E2205), and extra pneumatic propulsion tires (E2211).

You asked the Plan to pre-approve the wheelchair accessories. You say that You need these items. The Plan denied your request. The Plan says the impact guards and hub are not primarily medical in nature. Codes E2224 and E2205 are listed under Column II, and K0005 (Manual Bases) is listed under Column I. Therefore, payment of E2224 and E2205 is included in the requested K0005 code for the manual wheelchair. A separate request for these items should be denied as unbundled. Two extra tires exceed the member's need and cannot be covered.

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 the impact guards and hub (K0108), propulsion wheel (E2224), hamdrim (E2205), and extra pneumatic propulsion tires (E2211).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Axumin Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan.

You asked the Plan to pre-approve a Axumin PET with CT scan. You say that the requested Axumin PET with CT scan is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria.

The Plan must follow Medicare rules. Medicare rules say that PET imaging for initial anti-cancer strategy is non-covered for enrollees with prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a Axumin Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair seat elevation system and tub slider bench.

You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not considered durable medical equipment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The items 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 power wheelchair seat elevation system and tub slider bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.
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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin three or more times per day.
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 pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 4,
2020 to September 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the submitted records do not support the billing of DRG 190 and secondary diagnosis
code J96.01.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 190 (chronic obstructive pulmonary disease
with MCC) and secondary diagnosis code J96.01 (acute respiratory failure with hypoxia). 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 these services. Our reviewer says that the submitted records
do not support the billing of DRG 190 and secondary diagnosis code J96.01. Our physician reviewer found the
enrollee presented to the emergency department (ED) with respiratory distress and mild hypoxia. The enrollee
did not require BiPAP or intubation. The enrollee quickly improved with breathing treatments and steroids.
There is no evidence that the enrollee had, or was treated for, a lower respiratory tract infection or respiratory
failure. As such, diagnosis code J96.01 and the derived DRG (190) are not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from September 4, 2020 to September 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Breztri Aerosphere inhaler.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 a Breztri Aerosphere inhaler.

Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), complete mandibular denture (D5120), and simple extractions (D7140).

You asked the Plan to pre-approve the complete dentures and simple extractions. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.

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 a complete maxillary denture (D5110), complete mandibular denture (D5120), and simple extractions (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and power standing feature (E2301).

You asked the Plan to pre-approve a power seat elevation feature and power standing feature. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.

We looked at the file and Medicare rules. The requested items are non-covered. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature and power standing feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and power standing feature (E2301).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for full cast high noble metal crown (D2790) provided by a participating provider.

You asked the Plan to pay for a crown. You say that you would like the Plan to approve this dental work. The Plan denied your request. The Plan says D2790 is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for full cast high noble metal crown (D2790) provided by a participating provider.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for lab services (88361) provided June 23, 2021.  

You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan denied your request. The Plan says that this test was not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lab services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found WATS3D testing has high clinical utility. By prompting physicians to change their clinical management in patients with negative forceps biopsy results, WATS3D, used adjunctively to biopsy, directly impacts patient management, and improves patient outcomes.  

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 lab services have been met. Therefore, we decided that the Plan has to pay for lab services (88361) provided June 23, 2021.   

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
You asked the Plan to pre-approve the POV. You say that the item is medically necessary. The Plan denied your request. The Plan says the item 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 POV. Our reviewer says that you do not need this item. Our physician reviewer found there is no documentation that this patient has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is also no documentation that the you cannot use a walker or cane and that you can safely operate a PMD. 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 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve the power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network (OON) provider.

You asked the Plan to pay for physical therapy. You say that you have not had success with the participating provider. The Plan denied your request. The Plan says there are in-network providers available to provide the requested 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 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 physical therapy provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a core buildup (D2950), and a crown (D2752) to be provided by a participating provider.
You asked the Plan to pay for a core buildup and a crown. You say that a new crown is needed to ensure tooth is sealed properly and to protect existing root canal. The Plan denied your request. The Plan says that criteria has not been met for the requested dental 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. The Plan covers a core buildup and a crown when the services are medically necessary and reasonable. 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 a core buildup and a crown. Our reviewer says that the criteria for a core buildup and crown restoration and for a mandibular removable partial denture has been properly supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's criteria for coverage of a core buildup and a crown have been met. Therefore, we decided that the Plan has to pay for a core buildup (D2950), and a crown (D2752) to be provided by a participating provider.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need these items. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve flex foot system, Ossur ProFlex pivot foot (L5980).
You asked the Plan to pre-approve a replacement K3 foot. You say that see supporting medical documentation to have overturned for approval. The Plan denied your request. The Plan says the current foot is a K3 foot is still under warranty. Medicare does not cover replacement costs for items still under warranty.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve flex foot system, Ossur ProFlex pivot foot (L5980).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for debridement.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the requested provider has skills above and beyond the participating providers.
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 an out-of-network referral for debridement